Plan reinforces national guidelines
When NYLCare Health Plans of New York started looking at data on its congestive heart failure (CHF) patients four years ago, it found a big problem: 47% were readmitted to the hospital within 90 days, 72% of hospital admissions were related to CHF, and only 25% received the drugs of choice stated in national guidelines. Besides that, says medical director John Roglieri, MD, "Congestive heart failure was costing us a fortune."
So the health plan turned to Wilmington, DE-based Stuart Disease Management Services for help developing a comprehensive disease management program that would cut hospitalizations and costs while boosting compliance. A two-year study of 149 patients to determine the program's effectiveness after 12 months of implementation, found an 83% decrease in hospitalizations, a 100% decrease in emergency room visits, and an 82% decline in number of hospital days. Also, the number of patients receiving appropriate medications doubled to about 50%, and quality of life improved 44% as measured twice-yearly by the Minnesota Quality of Life questionnaire.
All numbers go up for NYLCare
Not only did the numbers improve forthe 149 program participants, but they also improved for NYLCare's CHF population at large, says Kenneth L. McDonough, MD, MS, vice president and medical director for SDMS. "The program has a coattail effect," he says. "We think physicians became so aware of the national guidelines with their high-risk patients and got those constant reminders that they started applying that improved knowledge to all their heart failure patients. That's encouraging because it means the health plan doesn't necessarily have to enroll everyone in the program to see some benefits."
Based on the results of the study, NYLCare has plans to expand the program to its 10 health plans in nine states.
The reason the program packs such a big punch, McDonough says, is that it provides physicians with a customized set of national guidelines and provides constant reinforcement for both physicians and patients. When SDMS first began developing its CHF program, it analyzed data from several health plans and found an underuse of appropriate medications, lack of implementation of national guidelines, lots of emergency care and hospitalizations, and a general difficulty among patients with managing their own disease. Perhaps the biggest issue they found was underuse of ACE inhibitors, a class of drugs that can improve symptoms and prolong life in nearly all CHF patients.
"We saw that practice patterns were not aligned with national guidelines, and we saw an opportunity to implement those guidelines to get increased use of appropriate medications and to get patients to more assertively self-manage their disease," McDonough says.
SDMS began by convening panels of participating physicians who reviewed literature and examined national CHF guidelines, especially those from the Agency for Health Care Policy and Research. A separate meeting was held to cover each chapter of the AHCPR guideline, and the physicians were given the opportunity to make changes and give their stamp of approval. "If national guidelines meet local practice customs and are approved by the audience, they are much more apt to be examined and followed," McDonough says.
Once the guidelines were approved, physicians received copies in the mail and attended educational meetings that stressed such issues as prescribing ACE inhibitors. More importantly, they started receiving individualized reports on each patient that customized the guidelines to that situation. Roglieri says that's what had the biggest impact. "There are too many guidelines, and they all get thrown away," he says. "The physician says `I've been taking care of CHF for 40 years, and here's how it's done.' So we just keep telling them. We say here's the name of the patient and here's what's going on. When something comes in and it's got your name and your patient's name on it, it's less likely to be seen as just another piece of junk mail."
The individual information on the patients comes from home visits done by nurses when a patient is released from the hospital and from weekly phone calls they make to inquire about the patient's overall health and special problems, McDonough says. "Even if the provider prescribes the proper medications, that doesn't mean the patient is going to fill that prescription or take the medication as scheduled. Our program helps patients follow orders, detects problems, and teaches patients how to manage themselves in between office visits."
The same nurse calls the same patient each week at a prearranged time and asks a set of questions designed to see if the patient's symptoms are worsening. Questions include whether they've been to the emergency department that week, if they've been weighing themselves daily, and whether they've been getting their prescriptions filled. If everything is normal, the physician gets the information by letter. If there's a problem, the physician is called or faxed immediately. Patients also receive monthly educational mailings that are targeted to a senior citizen audience on such topics as nutrition, medication compliance, and exercise.
Patient education is key, Roglieri says. "The patient owns the disease. If you've got congestive heart failure, it's probably going to kill you. We don't know when," he says. "Your doctor's got 22 patients in the morning and another 30 in the afternoon. It has to be your deal. You've got to take your medications, avoid salt, get some exercise, weigh yourself every day. We're going to call and ask you how you're doing. That's patient empowerment."
Helping patients manage themselves not only means better outcomes, but it also means less hassle for physicians. "Physicians love it," Roglieri says. "We get the patients off their backs. We tell them when a patient's getting into trouble. The patients wait for our phone call instead of theirs. What's not to like? Every physician needs an extra pair of hands and an extra pair of ears, and that's what we're giving them."
[For more information on CHF disease management, contact Kenneth McDonough, MD, MS, vice president and medical director for Stuart Disease Management Services, Little Falls Centre One, Suite 100, 2711 Centerville Road, Wilmington, DE 19808. Telephone: (302) 892-4435. John Roglieri, MD, medical director for NYLCare Health Plans of New York, 1 Liberty Plaza, New York, NY 10006-1404. Telephone: (212) 437-1563.]