Unique model provides disease management to home care patients

New approach to delivering care includes face-to-face interventions

When the home health nurses at Little Rock, AR-based Baptist Health Home Health Network began observing that many of their patients had poorly managed chronic diseases and were not receiving evidence-based care, the network designed a new approach to delivering care for patients with chronic diseases.

The home-based chronic care model, implemented in 2007, provides disease self-management support to home health patients with diabetes, heart failure, coronary artery disease, chronic pulmonary obstructive disease, and asthma.

The National Association of Home Care & Hospice has given its Excellence in Innovation Award to Baptist Health Home Health Network in recognition of its work in creating a better way to deliver heath care to patients with chronic diseases.

The goal is to reduce health care utilization and the rehospitalization rate by engaging patients in disease management.

The initiative was so successful that the department created 2020 Health Solutions to provide similar services for employees of Baptist Health under an arrangement in which the home health network will share in any health system cost savings, says Paula Suter, RN, MA, CNS, CCP, director of chronic care management for Baptist Home Health and 2020 Health Solutions.

"When we started telemonitoring services for our patients, we began noticing that many of our patients with chronic diseases were not receiving evidence-based medicine. What was more concerning to us was that many of these patients also had poor disease self-management ability and knowledge. They were not very engaged in disease management for a variety of reasons," Suter says.

The home health nurses were frustrated because they couldn't engage the patients in efforts to get their conditions under control and sometimes labeled them as noncompliant.

"At that time, our nurses didn't have the competencies they needed to engage the patient, especially those who are non-adherent to the plan of care or the competencies needed to help change behavior," she says.

Recognizing that the Centers for Medicare & Medicaid Services (CMS) and private insurers are moving toward value-based purchasing and that poor disease management affects patients' quality of life and often results in rehospitalization, the home health network made it a strategic objective to provide evidence-based chronic disease management, Suter adds.

The team researched the literature to identify the best practices in medical care as well as the best ways to educate adults and to effect behavioral change.

They looked at CMS demonstration projects that revolved around disease management and researched what the experts in the field were recommending.

"We took all of that and came up with a cohesive model for home health patients," she says.

Four areas of focus

The program has four key focus areas: a high- touch delivery system, theory-based self management, specialist oversight by advanced practice nurses, and technology.

"We found that when we provide all components of the program, rehospitalization drops significantly with the sickest of the patients," Suter says.

Before beginning the program, Baptist Health developed a chronic care course to teach clinicians how to effectively work with patients and change their behavior. The curriculum includes principles of motivational interviewing, methods to improve patient confidence with disease management, and principles of adult learning.

The course also provides information on expert guidelines and best practices for heart failure, diabetes, and chronic obstructive coronary disease care. When clinicians pass the course, they are considered a home-based chronic care specialist (HBCCS), Suter says.

"Most health care professionals don't receive this kind of training as part of their education. We work with the clinicians to help them hone their skills for patient engagement and behavioral change," Suter says.

The purpose of the program is to help people learn to keep their chronic diseases under control by modifying their behavior and adapting healthy habits, says Paula Evans, MSN, RN, CCM, CS, clinical practice specialist with Baptist Health 2020 Health Solutions.

"Our goal is to get our clients to make a commitment to take the smallest positive step. So many of them have lost confidence in their ability to stay healthy. If they can experience a small success, we can build on that. We use motivational interviewing to determine what they are willing to work on and to get to the crux of what might prevent them from being successful," she says.

In the home health program, the nurses work with patients who have been hospitalized because of exacerbation of their chronic disease as well as those who need home health services for other reasons.

"Patients are so overwhelmed when they are in the hospital that they often don't understand their discharge instructions or what they should do. They don't know what symptoms indicate that they should call a physician. They are a very sick population and require a good bit of support," Evans says.

Some patients are not referred for chronic disease management but when the nurses go into the home, they realize that the patient also has a chronic disease that he or she is having trouble managing.

For instance, the nurse or physical therapist may be visiting the patient after a hip replacement and learns that the patient has diabetes and a blood sugar level that is out of control.

"We are seeing more and more patients with two or more chronic diseases. Due to overcrowded emergency rooms, a shortage of beds, and reimbursement constraints, hospitals are under pressure to discharge patients as soon as they possibly can. Since patients are in the hospital only a short period of time, they don't have enough time to absorb all the education on self-management that they receive," Suter says.

Patients in the 2020 Health Solutions program are referred by the self-insured health care system, which identifies patients who are not managing their chronic diseases well.

The nurses in the home health program make several home visits in the early weeks of the program to comprehensively assess the patient for their needs, to learn about the barriers in the home, and to develop rapport with the patient. In the 2020 employee program, the nurses may meet with their clients in the workplace instead.

"Studies have shown that it takes face-to-face encounters to develop a trusting relationship with an individual. Provider services over the telephone don't work as well," Suter says.

After the relationship is established, the patient is supported by telephone calls from the home-based chronic care specialist nurse and the telehealth nurse.

The nurses use laptops with air cards to access current patient information, enter new assessment information, and to document the patient encounters while they are in the patients' homes or at the worksite.

"We have a lot of point-of-care assessment tools built into the software," Suter says.

For instance, if the nurse administers an assessment for depression, the computer system scores it instantly and the nurse can talk to the patient's physician about the need for medication or referral to a counselor, right on the spot if appropriate.

Because the nurses document during the patient encounter and don't have to rely on notes or memory, the documentation is much more complete than it would be if they didn't have the laptops, Suter points out.

About 160 patients use telehealth monitors, which measure typical vital signs such as blood pressure, pulse rate, weight, and pulse oximetry, along with disease-specific information. The devices can be programmed to ask patients questions about symptoms every day. The patients transmit the data over the telephone on a daily basis to a computer database at the home health network, which is monitored and acted upon by telehealth nurses.

"The telehealth nurses are very experienced. They review the data seven days a week and if they don't look right, they intervene before the patient ends up in the emergency department. Depending on the situation, they may call the patient, send out the home health nurse if needed, or call the physician for orders," she says.

The telehealth nurse also helps provide positive reinforcement for the patients. For instance, if a patient's blood pressure drops to the recommended level, the nurse will call and praise him or her for a job well done.

"This helps the patients understand what variables are important, and it reinforces self-management," she says.

Based on results from the CMS demonstration project, the agency hired advanced practice nurses in key fields, including pulmonary medicine, heart failure, and diabetes.

They oversee the care being provided by the nurse generalist, make sure evidence-based guidelines are being delivered, and intervene with physicians on the nurses' behalf when they report that patients are not receiving recommended care.

(For more information, contact says Paula Suter, RN, MA, CNS, CCP, director of chronic care management for Baptist Home Health and 2020 Health Solutions, e-mail: Paula.suter@baptist-health.org.)