After total healthcare costs decreased by 79% for at-risk heart failure patients who were followed after discharge by a team of RN continuum case managers and community health workers, Sentara RMH Medical Center expanded the program.

• The team meets patients at the hospital and visits them in their homes, conducts an assessment, and divides the workload depending on the needs of the patient.

• The case manager who is a certified heart failure nurse also sets up telemonitoring equipment that heart failure patients use to monitor their weight, blood pressure, and other vital signs.

• By teaming up with community health workers, the continuum case managers could double their workloads and work at the top of their licenses.

A pilot project at Sentara RMH Medical Center in Harrisonburg, VA, that paired community health workers and RN continuum case managers to coordinate post-discharge care for at-risk heart failure patients resulted in a 79% decrease in total health care costs for patients in the program.

Patients in the program also experienced statistically significant decreases in admissions, readmissions, and ED visits, says Patra H. Reed, DNP, RN, CNML, CCCTM, Blue Ridge regional director of integrated care management for Sentara Healthcare.

Sentara RMH Medical Center developed the role of continuum case manager in 2014 as a way to improve post-acute care for chronically ill patients with complex needs who were being readmitted to the hospital or frequently visiting the ED. The 238-bed hospital added community health workers two years later.

The patients targeted for the program had longer-than-average lengths of stay, a long list of comorbidities, multiple discharge needs, and often had psychosocial and financial issues, Reed says. Many didn’t qualify for home health or other resources.

The continuum case management program started with two RNs and quickly expanded to three.

“In the beginning, we focused on our very complex patients, many of whom had our most resource-consuming diagnoses: heart failure, sepsis, and pneumonia. We followed the most complex patients regardless of diagnosis, and some of them did not have the “big three’ diagnoses,” Reed says.

An analysis showed that the patients in the continuum case manager program had fewer ED visits, fewer readmissions, and lower costs of care after the program began.

Because of its success, the program was receiving more referrals than the three nurses could handle. When Reed’s team analyzed what the case managers were doing, they determined that the nurses spent at least 50% of their time on tasks that didn’t require the education and expertise of a registered nurse.

“After a comprehensive literature review, we decided to provide a better skill mix by adding community health workers to the program. This allows the RNs to work at the top of their licenses and to reach more patients,” she says.

The hospital foundation agreed to give the department a grant to pay for three community health workers for 18 months. After the results of the heart failure study, the foundation agreed to provide another six months of funding so the hospital could complete the study of patients with diagnoses other than heart failure.

Each community health worker is assigned to a continuum case manager and works with him or her as a team. They have an office that is offsite from the hospital, but spend a lot of time in the field and at the hospital meeting new patients and visiting patients who already are in the program. The heart failure team is at the hospital almost every day, Reed says. The other two teams visit several times a week.

By teaming up with the community health workers, the continuum case managers were able to double their patient loads from 20 to 25 complex patients to nearly 50. “The community health workers do a lot of the self-management education and community referrals. They help the patients navigate the healthcare system and assist with the financial paperwork that bogged the case managers down,” she says.

When patients are referred to the program, the continuum case manager and the community health worker visit them in the hospital, explain the program, and begin to develop a rapport. Once the patient is discharged, the team sets up a home visit as quickly as possible.

On the first visit, the team goes over the discharge instructions, answers questions, and makes sure that patients have follow-up appointments and plan to go.

“Transportation is a big problem. A lot of times, patients leave the hospital with an appointment but don’t go because they have no way to get there. We help them access transportation so they can see their physician for follow-up care,” Reed says.

Medication reconciliation is a top priority for the RNs, Reed adds.

“We try to reconcile the medications when the patient leaves the hospital, but often the medication in the home is different from what patients told us in the hospital. Often, the case manager finds other medications on the kitchen table or in the medicine cabinet. We make sure the patient knows exactly what they are supposed to take and we provide medication boxes if needed,” she says.

The certified heart failure nurse also sets up telemonitoring equipment that heart failure patients use to monitor their weight, blood pressure, and other vital signs.

After the visit, the continuum case managers and community health workers involve the family as they create a plan of care and set a schedule for follow-up visits and phone calls. They divide the workload based on the patient’s needs.

The nurses in the program manage the plan of care and concentrate on the clinical aspects of care. They work directly with the patients’ physicians and may accompany patients to physician appointments. The nurses make sure that each patient’s specialists and primary care physician are informed about the patient’s condition and other providers’ treatment plans. They work closely with the rest of the team on medication reconciliation.

The community health workers help patients navigate the healthcare system, connect them to community services when appropriate, and focus on the nonmedical part of the treatment plan, such as diet and exercise.

The nurses and community health workers touch base with the patients frequently in the beginning and taper off as the patients stabilize. Patients stay in the program for as long as needed. Most stay in the program for 90 days after discharge, but some heart failure patients may need support longer.

“The team makes up to six community referrals for each patient in the program. We make sure all of them are in place before we close the file. Patients can always contact the team for assistance after they are discharged from the program,” Reed says.

Before developing the community health worker role, the hospital staff reviewed the literature on the subject and talked to people from other organizations that employ community health workers.

“The main idea is that they are a trusted member of the community,” Reed says.

The team made a high school diploma a requirement, but the three people hired all had a college degree and work experience in a healthcare related field. Each had worked with a vulnerable population in a service area, as a pharmacy tech, manager for a homeless shelter, and in a home for disabled adults.

“All of them were already engaged in the community and had a good understanding of the resources that were available,” Reed says.

The hospital received a grant from the Virginia Department of Health and used their curriculum to train the community health workers. The curriculum includes communication techniques, safety instruction, resources in the community, and disease-specific education.

Heart failure patients took the Minnesota Living with Heart Failure Questionnaire, which monitors patient perception of quality of life, when they joined the program and again in 90 days.

“The results show that the patients felt their quality of life had increased dramatically. This demonstrates that supporting the emotional and psychosocial aspects of heart failure as well as medical issues can have a significant effect,” Reed adds.