Hospital program weds case, disease management

Readmissions, LOS cut for three chronic conditions

Responding to an internal study showing that diabetes, congestive heart failure, and chronic obstructive pulmonary disease accounted for a majority of readmissions at Memorial Hospital in Colorado Springs, CO, the hospital implemented an ambitious treatment program linking critical pathways to the hospital’s disease state management efforts.

The results have been dramatic:

• In the last year, quarterly emergency department visits for chronic obstructive pulmonary disease (COPD) have dropped from 50 to 15.

• COPD outpatient visits dropped from 48 to 26.

• Length of stay (LOS) for COPD dropped from seven days to 5.4 days.

• For diabetes, LOS dropped from 3.6 days to 2.4 days.

• Readmission rates for congestive heart failure (CHF) patients dropped from 14% to 8%.

• Emergency room visits for CHF fell by 22%.

In addition, when patients were readmitted, their symptoms were less severe and, consequently, the LOS for returning patients was shorter, says Barbara J. Newberry, MPA, RN, director of nursing support services and program director for disease management at Memorial.

Memorial’s strategy for treating these chronic, high-risk patients was to refocus its critical pathways to cover the entire continuum — from the physician’s office to home care — and to develop a disease management program to supplement the efforts of the hospital’s inpatient care managers.

Rather than picking up patients at an acute stage in their illness, when they appear at the hospital for an emergency room visit, Memorial’s care managers accept referrals to the program from community physicians who are tired of dealing with their most difficult patients, Newberry says. "Physicians can choose to refer their patients into the program for education, follow-up and rehab, or whatever they feel is needed," Newberry says.

When a patient is admitted, a nurse care manager tracks him or her along the critical pathway. Meanwhile, a nurse case manager — based outside the hospital — meets with the patient and family members and continues to monitor the patient’s care following discharge.

Newberry reports that because follow-up occurs immediately after discharge, this "care-case management" approach has served to increase coordination of hospital treatment and discharge plans. "Part of our disease management program is having a case manager assigned to a specific population of patients," Newberry says. "Then of course we have home care issues and patient education issues and social support. The whole gamut of services is brokered by the case manager on an outpatient basis for the patient populations we’re targeting."

Because the inpatient care manager and the outpatient case manager belong to the same program and report to the same employer, communication between the two is such that "we know what the heck happened while [the patients] were in the hospital," says Newberry.

Getting information back from home care, however, has proved a trickier proposition, Newberry acknowledges. The main difficulty there has been the delay in getting a computer system that would allow care and case managers to have a usable medical record that could be communicated across the continuum. "We’ve been looking at systems that would allow us to do that, but we haven’t been able to afford to purchase them here in the hospital," Newberry says. "The systems that we do have in place are locked into the person using them. They can’t be easily transported to other sites of care."

A compromise solution has been the development of a standard care flow sheet that summarizes the various events in a patient’s care. (See sample flow sheet, p. 178.) "For diabetic patients, for example, we have on that care flow sheet the fact that survival skills need to be done for a newly diagnosed diabetic," Newberry says. "And that is something we have agreed as a group needs to happen on the inpatient side."

Following the inpatient stay, the flow sheet is given to the nurses who will be seeing the patient in the home care setting. When the patient is no longer eligible for home care, the home care coordinators then refer the flow sheet along to a patient educator or outpatient case manager.

"So right now, we’re still using paper. But, of course, because we know we’re a team working together, our caregivers talk to one another," Newberry says. "We know who to call in home care to talk about a diabetes patient or a CHF patient or a COPD patient."

This arrangement works best, of course, when dealing with the hospital’s own home care agency. But Memorial’s care managers also pass standardized flow sheets to non-affiliated home care agencies. "We’ve had to work much harder at that in establishing relationships," says Newberry. "And of course it isn’t as tight as our own system. But it’s not like [these non-affiliated agencies] aren’t interested in seeing the data. It’s getting it to them that’s a little more challenging."

In light of the program’s promising numbers, Newberry and her colleagues are expanding it to measure and track patient satisfaction, quality of life, and functional status before enrollment and then at periodic intervals. They’re also looking at individual elements within the program to identify and single out those aspects that most contribute to positive outcomes for the patient.

For example, Newberry found that COPD patients who participate in Memorial’s pulmonary rehabilitation program tend to show a dramatic increase in their pulmonary function. "So we have discovered that that’s an important treatment strategy that we need to encourage more patients to come to — and also an important measure," Newberry says.

As with just about any hospital-based disease management program, however, problems arise with regard to reimbursement. Although Mem orial has attracted a "huge number of contracted HMOs and employers," its market is not yet fully capitated. As a result, by actively working to reduce the number of hospital readmissions for three major chronic conditions, Memorial runs the risk of losing revenue.

"When I started this program, I had some intense conversations with our CEO and our administrators in terms of what we needed to do, because we are still walking this fence in that we do get some reimbursement from people who come into the hospital," Newberry says. "And if we keep them out of the hospital, that’s going to impact our bottom line."

What sold administrators on the program was the prospect of creating greater efficiencies in the treatment of those patients who were admitted to the hospital. "In this in-between work we’re in, it’s our view that decreasing lengths of stay and getting costs somewhere in line so we’re not losing huge amounts of money every time somebody is admitted to the hospital is a benefit to us. We also know that the future is going to mandate this type of program."

For more information about Memorial’s care-case management program, contact:

Barbara J. Newberry, MPA, RN, director of nursing support services and program director for disease management at Memorial Hospital, 1400 East Boulder St., Colorado Springs, CO 80909. Telephone: (719) 365-5086.