Improve outcomes with chronic care disease management programs
Improve outcomes with chronic care disease management programs
Focus on patient-centered care produces best results
Not only can a disease management program help home health agencies reduce hospital readmissions and improve outcomes in preparation for pay-for-performance, but it can also increase staff satisfaction.
"Over the past 18 months our hospital readmission rate has dropped from 29% to 20%," says Paula Suter, RN, MA, director of the Center of Excellence for Chronic Care at Baptist Home Health Network in Little Rock, AR. More importantly, for home health managers who are looking for ways to recruit and retain nurses and therapists, the agency has found that staff satisfaction with the results of the agency's disease management model has reduced turnover from 20% to 6%, she adds.
Staff acceptance of the education, guidelines, and tools required by the chronic care disease management model did not happen overnight, points out Beth Hennessy, RN, MSN, administrator of the home health network. "We are asking clinicians to adjust their perspective and change their practice," she admits. "They receive additional training, participate in more case conferences, and have to demonstrate these new competencies as part of their own performance measures," she says. As data have proven positive results, staff members realize that the new approach to care is working and that they are really helping their patients, she adds.
Baptist's disease management program for chronic conditions was developed after a review of clinical, financial, and patient data showed an increasing trend of patients with chronic conditions, says Hennessy. The primary diagnosis might not have been for congestive heart failure (CHF), but the patient's inability to manage the CHF might result in a readmission, she explains. "We decided that a disease management program with evidence-based guidelines, education, and telehealth could help us teach patients how to manage their chronic disease and avoid unnecessary hospitalizations," she adds.
"We discovered gaps in education, such as CHF patients didn't know to weigh themselves daily," says Suter. "We also found that clinicians didn't always have the tools or skills to collaborate with the patient to identify problems and solutions to those problems," she says. Another gap discovered in their research to develop the program was the fact that even when patients are discharged with medications to take at home, they didn't always understand how to take them, or they would decide not to take them, without talking to the physician, she says. "We needed to bridge the gap between the physician's orders and the patient's behavior, as well as address the gaps in education for patients and staff members," she adds.
Education is a key part of any disease management program, says Joan Haizlip, MSN, RN, CS, director of programs and education at VNA First/Innovative Healthcare Solutions in Naperville, IL. "For years nurses have acted as preachers of health information, giving instructions to patients," she says. "Now, healthcare and education is more patient-driven, so nurses need to change their behavior and listen carefully to make sure patients understand what is taught," she adds.
Identify education needs to design program
When developing staff education for a disease management program, start by surveying your staff, suggests Haizlip. "You can't expect everyone to be knowledgeable about all areas, so first, find out what they do know," she says. For example, the survey should ask staff members to identify best practices in diabetes care or answer questions related to best practices for other chronic conditions. "Use the results of the survey to develop your staff education program," she says.
Also, don't rely on staff education programs to give your clinicians all of the tools they need, warns Haizlip. "You should have an expert resource on staff that any nurse can call if he or she has questions," she says. No clinicians can be expected to stay on top of all of the latest developments in best practices in all areas, so the clinician experts on your staff can support everyone, she adds.
A key part of the heart failure disease management program at North Shore Long Island Jewish Hospital Home Care Network in New Hyde Park, NY, is a two-day intensive training program that teaches nurses how to identify heart failure symptoms and how to utilize the care guidelines developed by the program, says Mary Ann Rosa RN, CS, GNP, MSN, nurse practitioner and consultant for the agency. "We also review the heart failure-specific patient education manual that was developed for the program, and we review the heart failure-specific re-visit notes and other documentation," she says.
Consistency in care is another important part of disease management programs, and staff education sessions, along with standardized teaching materials, can ensure that all patients receive the same evidence-based care, says Suter.
Another component of disease management that most home health agencies find critical is telehealth. "We use telehealth as a tool to monitor patients more closely without requiring a nurse to be at the home and to reinforce education," says Kathleen Pecinka, RN, BSN, telehealth manager, North Shore Long Island Jewish Hospital Home Care Network. Not only can the telehealth nurse identify potential problems early, but also a phone call to the patient can be made quickly to determine if a nursing visit is needed. "This early intervention prevents many crises that result in hospitalizations," she adds.
The additional education and tools, as well as training to help nurses identify solutions, have solved a problem identified by the North Shore agency when the program was first developed, says Rosa. "One of the main reasons that heart failure patients did not get the care they needed when they first showed symptoms was miscommunication between nurses and physicians," she says. For example, a nurse calls the physician to report that the patient had edema, but when the physician asks the nurse if the patient is fine otherwise, and the nurse answers "yes," the physician thinks that nothing is serious and does nothing except tell the nurse to let him or her know if anything changes. "Now, nurses are taught to use the SBAR method of communication," she says. SBAR, which is an acronym for Situation, Background, Assessment and Recommendation, requires the nurse to report the situation, the pertinent background of the patient's medical history, the nurse's assessment of the situation, and a recommendation for action, she explains. "By presenting the whole picture and offering a suggestion for Lasix to be prescribed, the nurse gives the physician enough information to judge the situation," she says. "We find that patients get the treatments they need before they reach a crisis situation with this approach."
Sources
For more information about development of disease management programs, contact:
Kathleen Pecinka, RN, BSN, Telehealth Manager, North Shore Long Island Jewish Hospital Home Care Network, New Hyde Park, NY. Telephone: (516) 876-6667. E-mail: [email protected].
Beth Hennessy, RN, MSN, Administrator, Baptist Health Home Health Network, 11900 Colonel Glenn Road, Little Rock, AR 72210. Telephone: (501) 202-7480. E-mail: [email protected]
Paula Suter, RN, MA, Director of The Center of Excellence for Chronic Care Management, Baptist Health Home Health Network, 11900 Colonel Glenn Road, Little Rock, AR 72210. Telephone: (501) 202-7480. E-mail: [email protected]
Joan Haizlip, MSN, RN, CS, Director of Programs and Education, VNA First/Innovative Healthcare Solutions, P.O. Box 9184, Naperville, IL 60567. Telephone: (630) 236-4603. Fax: (630) 922-3394. E-mail: [email protected].
Not only can a disease management program help home health agencies reduce hospital readmissions and improve outcomes in preparation for pay-for-performance, but it can also increase staff satisfaction.Subscribe Now for Access
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