HF program reduces readmissions by 49%
Coordination through continuum is key
Sharp Rees-Stealy Medical Center's heart failure disease management program reduced readmissions for heart failure by 49%.
- The physician practice's embedded case manager visits patients in the hospital, explains the program, and starts the educational process.
- A heart failure case manager contacts the patient by phone or in person before discharge, then follows the patient by telephone and monitors weight and other data transmitted from the electronic scale provided to patients.
- A case manager who works in the physician practice accompanies patients to their first follow-up visit and share the information with the heart failure case manager.
After Sharp Rees-Stealy Medical Centers implemented a heart failure disease management program, 30-day readmissions for the San Diego-based medical group practice's senior HMO patients discharged with a primary or secondary diagnosis of heart failure dropped by 49%.
"We analyzed data to identify trends in hospital admissions and readmissions among our chronically ill population and targeted heart failure because it is a major cause of readmissions in the San Diego area. One of our goals is to decrease hospitalizations and give our patients a better quality of life," says Janet Appel, RN, MSN, director of population health for Sharp Rees-Stealy.
In recognition of its innovative program, Sharp Rees-Stealy received the 2013 Doyle Award for Innovation and Leadership in Healthcare from MCG (formerly Milliman Care Guidelines). The medical group practice has more than 450 physicians and 21 locations and is part of Sharp HealthCare, with headquarters in San Diego.
A key element of the success of the program is developing a care team that works together and moves patients smoothly along the continuum of care without duplicating efforts and confusing patients, Appel says.
"Before we started this initiative, the inpatient and outpatient teams all had heart failure activities in place, but the effort was not consistent or coordinated. The hospital staff provided education and instruction while the discharge planners coordinated future appointments and follow up. The patient also received post-discharge hospital calls and more education and follow-up calls from the physician office. It was all good information, but it was delivered by many sources and could be piecemeal and confusing to the patient," she says.
Now the patient and care team create a shared action plan that is communicated to every caregiver along the way, driving patient-centered decision making, Appel adds. The educational process starts when patients are in the hospital and continues after discharge. "No longer does everybody in the continuum start at the beginning, but they build on the education patients have received from other team members," she says.
Care for heart failure patients is coordinated by a team of case managers who work seamlessly together. The heart failure care managers are the team leaders in the process and work with patients over the telephone from a central location. In addition, the team includes Sharp Rees-Stealy inpatient case managers who work in Sharp HealthCare hospitals and case managers embedded in primary care offices.
The heart failure case managers and the rest of the team work with the patients to set goals and support them in working toward the goals. "A big part is determining the patient's mindset and motivation. Each patient is very different in the way they want to approach care. For example, some may want to work only on their diet at first. Others choose an activity goal to pursue, while another may just try to accomplish weighing themselves each morning. We don't try to tell them what to do, but we help them achieve small successes along the way working on the things they want to work on until they learn how to self-manage their heart failure," Appel says.
When a Sharp Rees-Stealy patient is admitted to the hospital with a diagnosis of heart failure, the Sharp Rees-Stealy inpatient case manager notifies the heart failure case manager and then visits the patient. During the visit, the inpatient case manager explains the program, starts patient education, and tells the patient to expect a call or visit from the heart failure case manager. The inpatient case manager and the heart failure care manager collaborate while the patient is in the hospital and let the patient know that when they see their doctor, they will meet with the nurse embedded in the physician practice.
"Patients know that while their care will be coordinated by different nurses at different parts of the continuum, they all work together with the physician to provide coordinated care. When patients are discharged, they no longer feel like they're receiving fragmented care but see their care coordination as a team effort," Appel says.
When patients see their physician for follow up after being hospitalized, the case managers embedded in the physician offices meet with the patients, accompany them into the examination room and stay while they see the physician, and share information from the visit with the heart failure case manager. The nurses in the physician offices may see the patients briefly every time they come into the physician office or for a longer visit if they are alerted by the heart failure case manager that a patient is experiencing problems and would benefit from face-to-face support.
The program provides patients with electronic scales that ask a series of questions and transmit data back to the heart failure care management team, which checks the data every day to make sure patients are doing well.
The heart failure case managers may talk to the patient every day just after discharge then taper off to weekly calls. But when the data show that patients didn't weigh themselves, have gained weight, or report signs or symptoms that indicate their condition is worsening, the heart failure case manager calls to find out what's going on and intervenes.
Each heart failure case manager has a caseload of about 140 patients at a time.
The case managers typically follow patients for six months. "We give them the tools for self care during the first few months. They learn to weigh themselves daily and what to do when signs and symptoms indicate problems. After about six months, patients know how to take care of themselves," she says.
Part of the reason for the program's success is that it maximizes the time of each clinician and eliminates duplication, creating a seamless transition between team members, Appel says.
"In this day and age, with the emphasis on readmissions, we have to be efficient. This program takes all the resources we have and partners them together to create a care team. Everyone is giving patients the same message, introducing the next person who will be working with them, and preparing patients for the next step. Patients feel cared for and know that everybody is working together," Appel says.