Program provides support to publicly insured with CHF

Target: Reduced hospitalization, better quality of life

In just six months of operation, the congestive heart failure disease management program at Horizon/Mercy has resulted in few hospital admissions for some patients.

"People who used to be in the hospital every other week have had longer lapses of inpatient services," says Giavanna Ernandes, RN, MSN, APNC, Horizon/Mercy’s team leader for disease management.

The congestive heart failure program was begun last summer after the insurer looked at high utilization disease among its membership. Congestive heart failure (CHF) was one of Horizon/Mercy’s most expensive diseases to manage.

"We had a longitudinal case management program, but it had very strict guidelines based on ICD-9 codes and limited resources to manage the program," Ernandes says.

The patients with the highest utilizations, hospital admissions, and medication costs were targeted first.

As of December 1,142 members had enrolled in the program. Until the weather got cold, the plan was identifying 15 to 20 members a month. In December, 50 members were enrolled in the program.

Ernandes expects the number to increase during the winter months.

"In the winter months, people with [CHF] tend to get sick and end up being admitted to the hospital," she says.

When a member is identified for the program, the case managers make outreach calls to these patients to find out about their disease, their understanding of the disease, signs and symptoms they are experiencing, and if they are being followed by the cardiologist or pulmonologist.

"The case managers look at the whole picture. We don’t just call the member. That’s vital, but we also provide other kinds of support," Ernandes says.

They set up appointments with a pulmonologist and a cardiologist if necessary and interact with the member’s primary care physician. If they feel the member will benefit, the case managers set up a nursing visit. They send a pillbox that helps the members comply with their medication regime and a scale if the member needs it.

They call them regularly to remind them to take their medication appropriately and check their weight daily.

"With severe patients, the key is education. Once you get them out of the crisis, the disease is very manageable as long as they know the warning signs — weight gains and shortness of breath," Ernandes says.

In addition to using claims data from hospitals and emergency room visits, the case managers mine pharmacy data for ICD-9 codes to identify CHF patients who might not have been hospitalized or visited the emergency room.

"We make sure that our case managers reach all of the members with congestive heart failure," she says.

Once a member is receiving case management, the plan has an automated system for documentation and follow-up.

"The case managers develop relationships with the clients and get to know them. Nothing is written in stone. Some may call more frequently if the member seems to need support," Ernandes says.

Any member who has had one or more admissions in the past six months receives a follow-up at least monthly for six months. If there are admissions during that period, the follow up continues for another six months.

Members who have had one admission in the last year get a follow-up call and receive a follow-up every three months.

During those calls, the case managers remind the members to take their medication, find out if they need transportation to their checkup, give them a number they can call for advice, and follow up on their treatment.

Over the winter months, the case managers remind members with CHF to get flu and pneumonia shots.

"We do a lot of education. Congestive heart failure can be managed and members can live a fairly healthy life if they follow the regime," Ernandes says.