CHF program mixes leading regimens for success

Staff credit program’s multidisciplinary nature

A medical center and private cardiology practice in Omaha, NE, are breaking the cycle of dependence on hospital services that makes congestive heart failure (CHF) an economic burden on the health care system and a personal one on patients. The Heart Institute’s Heart Failure Center, a joint effort of the Alegent Medical Center, Immanuel Campus, and Heart Consultants, PC, provides a unique multidisciplinary disease management program that includes an electronic link to the emergency department, outpatient inotropic infusions, patient education, home health care services, and pastoral care.

Data show the program is working: Hospital admissions decreased by 30%, the number of hospital days by 42%, and average length of stay by 17% among 67 CHF patients followed for a minimum of one year before enrollment and 16 months after enrollment. Substantial cost savings also have been achieved, as one year of frequent visits to the center costs less than a single hospital admission for CHF. Patients are seen at the center an average of 15 to 20 times a year at an average cost of $2,000, compared to an average cost of $9,000 for one CHF admission.

"The Heart Failure Center maximizes the quality of life for a chronic debilitating disease," says Douglas Chapman, MD, FACC, director of the Heart Failure Center. "It gives patients a chance for state-of-the art management of medications, including medicines that are not yet on the market. It gives patients the opportunity to participate in their disease management through exercise, diet, and a better understanding of the disease process. All those things add up to a better quality of life, less hospitalization, and for the third-party reimburser, it’s also a cheaper way to go. So it’s a win-win situation for the patients and the insurance companies."

The Heart Failure Center seeks to provide consistent care, ensure patients are seen frequently, and prevent hospitalizations by adhering to a strategy that minimizes medication switching, promotes good patient-physician relations, and encourages patient participation in treatment, Chapman says. To meet those goals, the center has a team that includes physicians, nurses, a program nurse coordinator, a cost administrator, pharmacist, dietitian, recreational therapist, home health care nurse, and pastoral care chaplain.

Patients are assigned to a clinician group that follows protocols and uses standardized clinic visit forms established by the Heart Failure Center. For example, all patients with systolic dysfunction must receive an ACE inhibitor as long as they have no contraindications to those drugs. Patients are seen weekly until they stabilize and then at least every six weeks. At each visit, the patient stays in a treatment room for about one hour and is visited by the physician, nurse coordinator, pharmacist, and dietitian. Patients attend rehabilitation classes twice a week and quarterly luncheons featuring speakers, low-sodium recipes, and interaction with patients and families. Patients can reach either Chapman or the nurse coordinator by telephone 24 hours a day.

"We have a touchy-feely set-up," Chapman says. "Patients feel they can call at any time. I know all the patients, and I can help them personally. It can be so frustrating for doctors on call who don’t know the patients. It’s easier to just tell them to go to the emergency room."

Emergency department link

Although the center tries to keep CHF patients out of the emergency department, it keeps a readily accessible database up to date for those inevitable occasions. The database includes records of past echocardiograms, cardiac catheterization, bypass procedures, radionuclide ventriculography, and oxygen consumption results as well as patient trends in weight, blood pressure, subjective symptoms, renal function, and electrolyte status. Strategy calls for the emergency department physician to give intravenous diuresis until the patient improves or can be transferred to the Heart Failure Center. Inpatient admission is avoided, if possible, Chapman says.

A home health care nurse assesses patients between clinic visits and can report changes to the program coordinator 24 hours a day so medication can be altered if necessary and hospitalization prevented. The nurse makes sure patients remember their clinic appointments and also sees them during their clinic visits to reinforce information on medications and diet.

Patients with advanced CHF (New York Heart Association Class III and IV) who are taking as much oral medication as possible with no symptom relief receive outpatient inotropic infusions. The stations are designed for infusions of milrinone and dobutamine as well as IV fluids and diuretics. Patients receive infusions for four hours two to three times a week for eight weeks and then once a week as symptoms improve. "It doesn’t make the condition better, but it does provide symptom relief and improve quality of life," Chapman says. "It also provides emotional support as patients spend time during the infusions with people who share their problem."

Data collection

The Heart Failure Center is working to keep its database current on all patients since the program’s conception and is planning to hire a staff person with that primary responsibility. Hospital admissions, length of stay, and total number of days in the hospital are tracked for patients in the program and compared to CHF patients seen at the medical center who are not in the program. Patients also fill out a quality-of-life questionnaire every three months. Cost data are collected through the hospital’s cost center, which tracks all revenue from outpatient infusions and other procedures as well as ongoing costs of patient care including supplies and salaries.

Without the data collection, the program wouldn’t survive, Chapman says. "Because of the climate of health care that keeps patients away from specialists," he says, "it’s important for us to show that we can do a better and cheaper job of taking care of patients. That’s going to be the only way to divert patients to specialists.

"The understanding of this disease is so rapidly changing that the treatment and the medications that come out are rapidly changing. A lot of patients who go to primary care physicians are still being treated in the way we treated this disease back in the 1980s. Or they aren’t being treated at all. The condition cannot be reversed, but we try to make the time before death as good as possible."

[For more information, contact:

Douglas Chapman, MD, The Heart Failure Center, Alegent Medical Center, 6828 N. 72nd St., Suite 6100, Omaha, NE 68112. Telephone: (402) 572-3300.]