Reminder system prompts CMs to provide education

Pilot program part of hospital’s QI initiative

When the Hunter Holmes McGuire Veterans Affairs Medical Center (VAMC) in Richmond, VA, participated in a national performance measures initiative for congestive heart failure (CHF) patients, the administration was not pleased with what it saw.

Although the staff were certain that the case managers were giving the patients the required educational materials, they often weren’t documenting it. One of the Veterans Administration performance measures is how well a hospital provides written instructions on diet, activity, medication, and weight to congestive heart failure patients.

"We knew a lot of education was being provided, but our scores showed us to be on the lower end of the performance improvement scale when it came to documenting education to our congestive heart failure patients," says Mary Jacobs, RN, PhD, quality management coordinator at VAMC.

Working with the case management department, the hospital quality management team launched an interdisciplinary program aimed at changing the behavior of the hospital’s case managers and improving the education of the patients at the same time.

Patient education at the VAMC has three components: a patient education brochure produced by the VA for use nationwide, a packet of supplemental information, and a class that further addresses issues that arise with congestive heart failure.

"We wanted to change the process to improve upon providing information to inpatients with a principal diagnosis of congestive heart failure," says Mark Zunk, RN, MS, quality management nurse.

To strengthen the program, the hospital came up with a series of strategies designed to improve education for CHF patients and their families.

The heart of the program is a clinical reminder system modeled after the VA’s technique to remind physicians of preventive measures.

"If a patient meets the criteria for a preventive measure, such as needing flu vaccine, cancer screening, or mammography, a reminder to physicians pops up on the patient’s electronic chart during a clinic visit," Zunk says.

The hospital’s information technology service developed a similar clinical reminder to prompt the case managers to conduct patient education and to document it. When a patient is admitted with a congestive heart failure diagnosis, the case managers on the medical unit are alerted.

When they look at the patient’s electronic chart, a reminder pops up prompting them to conduct congestive heart failure education with the patient and give them the required written materials.

When the case manager gives the patient the material, she clicks on the screen to satisfy the clinical reminder. "After the case manager gives the patient the educational material, he or she documents this in an education progress note, which in turn satisfies the clinical reminder for CHF education," Zunk says.

Case managers at the VAMC are assigned to each unit and frequently see patients on the floor as part of the treatment team. They work with the pharmacist and the physician on discharge information for the patients.

For instance, the case managers may work with the pharmacist to set up boards or containers to help patients keep track of a complicated regime of medicines, Jacobs says.

Since many of the patients have multidiagnoses, such as diabetes, chronic obstructive pulmonary disease, and coronary artery disease, the case managers work with the entire treatment team to educate the patients.

"If the case managers feel that patients need additional information, they can call in the dietitian, pharmacist, or another member of the interdisciplinary team," Zunk says.

For instance, the dietitian may be called in for further education on restricted sodium intake. The pharmacist can give more in-depth instruction on the medications and how they should be taken.

"If the case manager finds that a patient needs a consultation, he or she initiates the consult and coordinates the care," Jacobs says.

If patients need it, the program provides them with scales, blood pressure cuffs, and paper tape measures to take home so they can monitor their weight, girth, and blood pressure.

If the hospital’s system for clinical reminders in progress notes is successful, it will be implemented in other VA hospitals nationwide.

The program now is in Phase I of the quality improvement program. Phase II will look at utilization to determine if providing the education to CHF patients reduces utilization.

"What we have begun to do is collect data on congestive heart failure from the utilization managers. We want to be able to analyze before and after measures to determine if we are improving patient outcomes such as decreasing length of stay, reducing unplanned admissions, and decreasing emergency room visits," Zunk says.