Humana CHF program cuts costs, admissions

Regular telephone contact improves quality of life

A two-year study of nearly 5,000 congestive heart failure (CHF) patients enrolled in a disease management program found a 57.5% drop in hospital admissions for all diagnoses and a 61.1% reduction in inpatient health care costs. (See graph, p. 174.)

The patients, all members of the Louisville, KY-based Humana Inc. health plan, also saw a 58% drop in hospital days, and a 48.9% decrease in emergency department visits as a result of participating in the program from Cardiac Solutions of Buffalo Grove, IL.

Other results included a 34% drop in sodium intake for patients on the program a year or more and an 8% increase in functional status in the first year of the program as measured by the Duke Activity Status Index.

"There is no question that we are taking better care of our congestive heart failure patients," says Richard Vance, MD, Humana’s vice president for population health improvement. "We believe the results of this program provide the blueprint for care of CHF patients nationwide in the future."

The key to the success of Cardiac Solutions’ program, which was developed under the name MULTIFIT by researchers at Stanford University, is managing the patient, not just the CHF, says Cornelia Tilney, vice president of marketing for Cardiac Solutions’ parent company, Ralin Medical Inc. Claims data show that when you look at patients who have had a prior hospitalization with a primary diagnosis of CHF, 50% to 60% of the inpatient costs are for non-CHF conditions, she says. Cardiac Solutions can bring the costs down 70% for CHF, and 40% to 50% for other costs.

Establishing relationships with patients

Cardiac Solutions employs cardiac nurses with at least five years of experience — the average is 10 years — in five regional offices to help patients manage their symptoms at home through regular telephone contact. The program begins with a home visit from one of Cardiac Solutions’ contracted home health agencies that assesses the patient’s physical and psychosocial status, diet, and medication compliance. Patients receive a workbook with a simple format that teaches them how to manage their disease. Nurses go over the information chapter by chapter with them on the telephone. The nurses follow a scripted format for the calls, asking a series of questions and entering the responses into a database as they go. Patients may also call the nursing center themselves if they need immediate help.

"The nurses work to develop a relationship with the patient," Tilney says. "The same nurse will call the patient each time, and they send short biographies and photos of themselves to help the patients feel comfortable. They also send postcards with congratulations when the patients reach certain milestones. They are not only a highly competent clinical resource, but also a motivator, coach, and cheerleader."

Protocols based on AHCPR guidelines

The protocols of the program are based on national guidelines from the Agency for Health Care Policy and Research in Rockville, MD, and the American Heart Association in Dallas. These guidelines often fail in clinical practice, MULTIFIT’s developers say, because no one has the specific responsibility of making sure they’re implemented and because of logistical problems, including little time for individual patient-physician contact.

In this program, the nurses follow protocols on lab management, medication management, lifestyle management, and symptoms. If the patient has a cough, for example, the protocol helps the nurse determine whether it’s from the medication or perhaps a respiratory infection and what action to take. If the situation appears urgent, the nurse will send the patient to the physician immediately.

If guidelines and treatments don’t match, the nurse will point out the differences and ask the physician whether any changes should be made. Besides providing a check-and-balance system, this approach also takes some pressure off the physician’s time, Tilney says. For example, one area the nurses focus on is the use of angiotensin-converting enzyme (ACE) inhibitors, which sometimes are not prescribed at optimal doses suggested by national guidelines. In a 1997 study on MULTIFIT published in the American Journal of Cardiology, the number of patients who received target doses of the ACE inhibitor lisinopril increased by 82%.

The results of the phone conversations are reported to both the physician and the patient, along with results of written questionnaires the patients complete periodically. Seeing their progress on paper is a good motivator for patients, Tilney says. If patients know someone is keeping track of their sodium intake, for example, they’re much more likely to watch their diet.

When Cardiac Solutions began the CHF program, all contact was face to face. But when the company got the national Humana contract, the frequent home visits became logistically impossible. So they tried the telephone method and found that the results were just as successful. "We found that when we have patients on the phone, we have their undivided attention," Tilney says. "When you’re in the home, the patient may be distracted by the TV or the cat or the phone ringing."

Vance says the program combines the efficiency of telephone contact with the personal touch of as-needed home visits. "It’s more practical than having every contact be a visit from a home-health nurse. With those nurses, their car time is downtime unless you have sophisticated technology in place. This way, we’re using their time more efficiently."

Cardiac Solutions’ ability to reconfigure the program to meet Humana’s needs is one of the keys to its success. "The changes were done in collaboration with us, and that allowed us to get buy-in from our physicians," Vance says. "Their disease managers have earned the trust of our physicians as well as our patients. Both the patients and the physicians feel comfortable calling the nurses. This model is showing the way that disease management can restructure health care."

For more information on the Cardiac Solutions program, contact the company at 4371A Abbott Ct., Buffalo Grove, IL 60089. Telephone: (800) 343-6311.