Improve outcomes, take step toward success with pay for performance

Disease management programs reduce hospitalization and number of visits

(Editor's note: This is the first of a two-part series that looks at how disease management programs within home health agencies can better position those agencies to be successful under a pay-for-performance program. This month we discuss the components of a disease management program, staffing, and education. Next month we look at how the program can be expanded to serve patients who are not homebound.)

As home health agencies look for ways to improve outcomes and increase their potential for success within a pay-for-performance reimbursement system, disease management programs that allow staff members to specialize in care for specific types of patients may be the road to success for some agencies, according to experts interviewed by Hospital Home Health.

Implementing a disease management program requires several components that increase staff members' competence and provides standardized guidance for care, says Joan Haizlip, RN, CS, MS, cardiopulmonary clinical nurse specialist at VNA First, a Willowbrook, IL-based network of community-based home care agencies that has developed diabetes and cardiac care disease management programs. "We saw disease management programs growing in importance a few years ago and we wanted to develop tools that agencies can use to set up programs for different diseases," she says.

"A true disease management program in home care incorporates evidence-based care and critical pathways, some form of remote monitoring, preventive education, the ability to work with other providers such as insurance companies, and the capability to care for patients beyond the traditional episode of care." To be successful with a disease management program, the home health staff have to go beyond thinking of home care only as skilled nursing, Haizlip says.

"At this point, disease management in home care is so new that we don't know what the implications for Medicare reimbursement will be in the future; but we do know that having a disease management program in place has allowed some agencies to market their services to private payers on a fee-based service," she says. Other agencies do report better outcomes for patients and fewer re-hospitalizations for high-risk patients, Haizlip adds.

"We implemented a cardiac disease management program in the past year and focused first on congestive heart failure [CHF] patients," says Sharon Jones, RN, MSN, executive vice president of clinical services for VNA of Cleveland.

"We have 11 nurses and two licensed practical nurses dedicated to the Care Watch team, which now cares for CHF patients, as well as diabetic patients who also have CHF," she says. The focused care received by cardiac patients has reduced her agency's rehospitalization or visits to the emergency room by cardiac patients by more than 30% since its implementation, Jones says.

Team approach works best

The team is multidisciplinary and, in addition to nursing staff, includes physical and occupational therapists, as well as a behavioral health nurse, says Jones. "The behavioral health nurse was already a part of the home health staff, but we now include her in the Care Watch program," she says.

"Many of our patients have a high anxiety level that makes them head directly to the hospital when experiencing difficulties instead of trying to talk to a nurse," Jones reports. The behavioral health nurse helps patients learn to deal with their anxiety so they can try self-help measures at home or take time to talk through their symptoms with a nurse before they panic and head to the hospital, she explains.

Education for patients in a cardiac disease management program is emphasized, focusing on enabling the patient to monitor his or her symptoms, follow medication directions, and assume responsibility for managing the disease, says Haizlip. "Standardized teaching booklets are important," she says.

Not only do nurses review the material during home visits, but telehealth nurses can reinforce teaching by saying, "Turn to page 10 of your booklet and let's see what is recommended when you notice weight gain." Consistent educational tools also mean that every nurse is teaching the same thing in the same manner, she adds.

Some form of telemedicine is essential for a disease management program, says Haizlip. For cardiac care programs, the telehealth staff member must be a part of the cardiac team and should use a questionnaire specific to cardiac care when making calls, she says. "It's important that the nurse making the call be good at recognizing symptoms of distress and be very familiar with cardiac illnesses because it will be this staff member who makes the decision as to the need for a nursing home visit or a visit to the emergency room," she explains.

"The telehealth component also increases contact with the patient to reassure them and to reinforce teaching without increasing visits," points out Sharon Grubb, RN, BSN, in-house nursing supervisor at Porter County VNA in Indiana.

"We find that patients are more compliant because they know that someone is concerned about them and will check on them to make sure they are taking medications correctly and monitoring their symptoms," she explains.

While some agencies choose not to designate one or two staff members as the full-time telemonitor staff, instead allowing all nurses who see patients to handle it, Jones has one advanced practice nurse, whose specialty is cardiac care, handle the telehealth calls. "She not only handles the telehealth calls to patients but she serves as a valuable resource to other team members," she adds.

Use clinical pathways

Clinical pathways that are evidence-based are another important component of a disease management program, says Haizlip. The use of pathways ensures that all patients in the program are receiving the same standard of care and that every treatment option is considered, she explains.

Some nurses may be reluctant to commit to what they perceive as a very structured plan of care that a critical pathway represents, says Grubb. "Participating on a disease management team is more difficult because technical skills must be higher and there are more protocols to follow," she admits.

"We did expect staff members to be tentative about the program and were not surprised to hear questions about how the program would work and would it really affect outcomes," says Jones. Because she did not have to hire new employees to form the Care Watch program, she asked for volunteers who wanted to move to the dedicated staff. "I found that a lot of nurses wanted to be a part of the program for several different reasons," she says.

Continuing specialized education for treatment of cardiac patients as well as association with the telemedicine component of the program were key attractions, says Jones. "Many nurses saw this as a way to advance their skills and be a part of a prestigious unit of the agency," she says.

Choosing the right people for the disease management team was important, says Jones. "We looked for nurses who did have experience in acute or cardiac care even though we knew we'd be offering them additional training," she says. "Although the RNs came from existing agency staff, we did hire two LPNs with acute cardiac experience from the community." It is important to find staff members who are interested in staying on top of the latest research about cardiac care, she adds.

Just as it is important to choose staff members carefully, be sure you recognize which patients are appropriate for a disease management program, says Jones. "Because our program focuses on cardiac disease, we admit patients with a cardiac-related primary diagnosis," she says.

Patients must be able to manage care for themselves or have a caregiver who can oversee medication, dietary restrictions, and monitoring, she says. This means that patients with cognitive problems, no caregiver, or a history of noncompliance are not appropriate, she adds.

"We also look for patients with disease management in their mindset," points out Grubb. "We want them to assume that they are responsible for their care as opposed to thinking that the doctor will take care of them," she explains.

"I believe that our disease management program gives us a definite advantage as we approach pay for performance," says Jones. "It gives us some tools to use to better manage our patients' care and it does improve outcomes."


For more information about disease management programs in home care, contact:

  • Joan Haizlip, RN, CS, MSN, Cardiopulmonary Clinical Nurse Specialist, VNA First, 6855 Kingery Highway, Willowbrook, IL 60527. Phone: (630) 778-3478. E-mail:
  • Sharon Jones, RN, MSN, Executive Vice President, Clinical Operations, VNA of Cleveland, 2500 E. 22nd St., Cleveland, OH 44115. Phone: (216) 931-1380. E-mail:
  • Sharon Grubb, RN, BSN, In-House Nursing Supervisor, Porter County VNA, 501 Marquette St., Valparaiso, IN 46383. Phone: (219) 462-5195. Fax: (219) 462-6020. E-mail: