Three approaches to telemanagement
It’s a simple concept: Use trained caregivers to stay connected with CHF patients over the phone. Here’s how three different facilities make it work for their program.
Case 1: The heart failure and transplantation unit at MCP Hahnemann University Hospital, Philadelphia.
It takes four full-time nurses to keep up with the needs of 800 CHF outpatients. One additional nurse works with in-patients, teaching and interacting with house staff.
If it’s a clinic day, as many as three out of the four nurses will be on the phone. "More often than not, they’re on the phone all day," says unit director, Jane Fitzpatrick, MD.
The nurses all have bachelor’s degrees in nursing. Some are advanced practice nurses. Fitzpatrick says it’s preferred if the nurses have a master’s degree, such as in education or practical nursing because it is helpful in their roles as patient counselors and teachers. There have been "diploma nurses" on the phones as well.
"It’s probably not necessary all are advanced practice," Fitzpatrick says, adding what counts is to have had the training and experience that gives some autonomy to the job, which is very different from the traditional office nurse. Overall, there is a "nice mix" of experience and training among the telephone staff.
They need it, she says, because they are handling so many different tasks over the phone. For example, patients may need direction with their diuretics because they have gained two pounds. Some may be renal patients, with delayed response to diuresis, so it may take longer to see the desired effects of the therapy. Others may be upset about their symptoms or need explanation about how to take their medicine or need to hear again why they are taking it. Nurses keep up with how other doctors are treating the patients — making sure the patients haven’t been taken off standard CHF therapies. Those cases, in particular, call for some diplomacy with consulting physicians who may not realize an ACE inhibitor cannot just be stopped.
Standard issue: Nurses
Each nurse gets an independent outside phone line and personal voice mail.
They are armed with photo charts of all medications patients usually receive and give a copy of the grid to each patient. All is standardized so the nurse can instruct the patient to trace a finger down a particular column and over two others to find the right one to take. But with generics coming out with different versions of the same drug all the time, the task still is difficult. Patients learn they need to come to the phone with their drug grid and their medication containers so they will know what to do.
Nurses also use a sliding scale for diuretics. If patients begin to gain weight, there is a corresponding response that is appropriate for them. Fitzpatrick says few patients are able to regulate their own diuretics at home and usually call in with their changes in weight to be advised on how to adjust diuretic dosing. "The majority of patients are not facile with that," she says.
Standard issue: Patients
Beside the medication charts, patients can get automated prescription refills. Pharmacists know containers have to have the medication name on them as well as instructions. Prescriptions are verified with the unit to make sure dosing and instructions stay current.
Patients can reach the nurses during regular business hours. All other times, their calls go to on-call staff. At the end of each shift, the nurses sign out to on-call staff and the next shift that will be coming in the next day.
At the beginning of a shift, staff can listen to the sign-out report and know what happened the night or day before and what may be expected to happen during the day. Often, a patient who may have called in the night before needs a follow-up call to make sure everything is under control and that he or she isn’t stressed, since it can be frightening to have to call at night, Fitzpatrick says.
"It’s upsetting to have to call in at night. But nurses can reassure patients, saying It’s OK that you have these symptoms. We should be expecting this, and we have ways to help.’"
An exception is pre-transplant candidates, who work through their assigned case coordinator.
Days are divided into three parts for nurses who handle the phones: receiving calls, consulting doctors about them, and getting back to the patients with instructions.
Fitzpatrick says nurses are encouraged to learn how to anticipate the doctor’s response, so they will say to the doctor, "I know when this usually happens, you tell the patient to do this — is that right in this case?" Not only does anticipation help with the interaction with the physician, but the patient can be prepared, too. Before ending a call, the nurse can prepare patients by telling them how the doctor probably will instruct them.
Patient charts are updated as changes happen. Staff also try to determine any trends they are experiencing, such as patients who are calling a lot. That could indicate there are deeper problems or issues that need to be addressed, she says, such as if patients are anxious or do not have a good support system at home.
"What we are trying to get across is a concept that this is a partnership. It does no good to give patients a treatment routine they are not able to follow," Fitzpatrick explains.
Fitzpatrick says these are some common situations that phone staff not only have to know about, but attempt to search out and diffuse:
- Be wary of confused patients. Patients often do not understand what they need to do and which medication is which.
- Be careful when giving medical or drug information over the phone. Use a standard chart, get patients to read the directions and other drug information on the bottle over the phone to you so you know you are talking about the same prescription. Make sure the drug name and directions are printed on the bottle, even refills.
- Tell patients to avoid finishing a prescription before getting a refill. Not only do patients run low, but if they use the last pill, they have nothing to use as an example when they get on the phone for help.
- Verify with the pharmacy what medications patients are taking so dosages stay current and everyone stays on the same page.
Look out for pitfalls
Other physicians treating your patients may change a prescription or instruction that is vital to controlling CHF. Fitzpatrick says her team really urges all physicians to keep in touch with them about any new drugs or instructions patients may be getting after an appointment — which could be something completely separate from CHF, since comorbidity can be common. "We like to be on top of that," she says. "A lot can happen between patient visits on clinic days."
"We’ve seen some disasters that can befall patients," she continues, noting it can often be traced back to an outside physician changing the regular routine. He or she may stop the ACE inhibitor because the blood pressure is low. "That’s really unacceptable," Fitzpatrick says. Other doctors may take patients off of diuretics when the team has been trying to titrate them on beta-blockers. "Not being on the same page could lead to needing to admit the patient; it can lead to an admission that can be avoided."
The patient’s diet should also be considered. Be aware of how consistently patients eat particular foods. Green, leafy vegetables, for example, contain a lot of vitamin K, which can affect the absorption of drugs like Coumadin. So a patient who eats a lot of these foods may need to be put on higher doses to get the right amount of drug in the body. But if the diet changes, more drug may be absorbed, sometimes becoming harmful. Grapefruit juice is another potential confounder. It can add to the absorption of antihypertensives. (Editor’s note: For more information on the effects of grapefruit juice on drug absorption, see the April 1999 issue of Pharma-ceutical Research, produced by the American Association of Pharmaceutical Scientists.)
Patients suffering from pulmonary pressure caused by excess fluid build up may get relief from a nitroglycerin tablet or spritz with the spray. "We have had a very good success rate," Fitzpatrick says, noting it may be needed especially at night, when patients lie in bed and fluids can settle. Many calls are prompted when this happens and patients wake up short of breath and can become excited.
Fitzpatrick says the key to a successful telemanagement service is to offer patients as much easy access to help as possible. She says her unit is just starting to make e-mail available to patients, which will help them communicate with staff without having to call. Staff also can leave written e-mails to the next shift as part of their sign-off routine. And ultimately, having patient files available in an electronic format would make them more accessible as well as make them easier to update.
Case 2: Vivra, a telemanagement contractor for patients in south Florida, Massachusetts, Rhode Island, Connecticut, Virginia, Maryland, and Delaware.
A staff of 25 registered nurses manages 2,800 patients with CHF for this telemanagement contractor, says Vivra vice president Frank Basile, MD. Nurses have either formal training in CHF management or a "tremendous amount" of experience working with cardiovascular patients. Nurses work an eight-hour shift each day.
Insurance companies usually contract with Vivra to cover their customers in a particular region, then the firm gets involved with the area’s doctors. Vivra operates in south Florida, the Northeast (MA, RI, CT), and the Mid-Atlantic (VA, MD, DE). Calls may come from any of the regions, but they go to the telemanagement center in Maryland.
Basile says there are three primary goals Vivra tries to accomplish when interacting with patients by phone:
1. Understand and assess patient symptoms (such as breathlessness or changes in weight).
2. Monitor the level of compliance (with items such as diet and medication).
3. Emphasize and repeat key educational messages (to make sure messages are understood).
"That’s really it in a nutshell," Basile says. "If you can achieve these things over the phone, you are going to do very well."
Standard Issue: Vivra and physicians
Nurses are guided through the course of each call with a computer software package. Basile says Vivra’s company protocol for handling each call is embedded in the software. Depending on the particular needs of the caller, questions and alerts pop up on a screen to guide the nurse handling the call, making sure Vivra’s three main goals are achieved.
Vivra also sends a form to the patient’s doctor to fill out according to the patient’s treatment. Copies of the form go to the doctor, Vivra, and the patient.
"We’re all on the same page," Basile says. He notes that the form represents what the doctor wants to see happen with the patient’s treatment. Any changes in care prompts an update on the sheet and distribution of the new copy.
Basile says patients receive an entire CHF curriculum. They learn how to create a picture of themselves, the status of their disease, and the routine they need to do to stay in control. "We work very hard to make sure they follow it," he says.
Patients learn how to assess symptoms such as edema. They learn what pitting edema is, the importance of regular weigh-ins, and what to do if their status changes. In many cases, Vivra can call the patient’s physician or dispatch someone to the home to help.
Basile says Vivra’s primary clients are insurers, but with the changes in managed care, he expects to be doing more business with independent practice associations.
Case 3: Sharp Healthcare, San Diego.
Sharp Healthcare is using its five hospitals in San Diego to test the best treatment strategies for CHF patients, says Beverly Carlson, RN, MS, CCRN, the system’s project director for cardiac research.
Patients tend to be older than those who go to transplantation centers such as UCLA, with average ages of 73 to 74. And because San Diego is such a large area, telemanagement helps keep track of patients who may not be able to visit facilities in person, especially if they are immobile due to their age.
Testing of a multidisciplinary approach to disease management began in January 1996. Three hospitals tested the procedures on 240 patients, and the remaining two hospitals acted as controls.
Patient care brought together social services, pharmacists, and nutritionists to help with patient teaching while patients were still in the hospital.
A three-ring binder of easy-to-read standardized educational materials about the disease, medications, and care is issued to each patient.
Cardiac nurse home visits are conducted for six months after discharge to monitor progress and teach self-care, then the nurses "pass the stick back to the case manager" for telemanagement, after patients have been shown how to manage the disease day to day.
Monthly support meetings are held, featuring different topics, such as diet. Meetings include plenty of time for questions and answers and are attended by the clinicians from many disciplines as well as case managers.
Kickertips, a publication named by the patients, is distributed quarterly. It repeats a lot of the topics covered in the monthly meetings for the patients who could not attend and reinforces the themes for the patients who did.
During the study, telemanagement nurses were concurrently testing contracted software developed by Pfizer Inc., assessing how helpful it could be in monitoring these patients as a beta-site for the drug company.
Tailor your patients’ protocols according to their particular needs. "To think one thing will work for everybody is naive," Carlson says, noting the procedures set up to work with the patient from hospitalization to home should be an entire program that includes telemanagement. She says her health system’s whole concept is to train patients to be able to take care of themselves the way diabetics handle their condition.
"You really need to look at patient stratification," she says. Assessing each patient according to functional status, age, and comorbidity ("In that order!" she insists) is essential to making the plan fit the patient. It’s important to note that in assessing functional status, Sharp doesn’t use the traditional New York Heart Association classes, because Carlson notes their validity hasn’t been proven like the Specific Activity Scale, which she says was developed by Goldman and fellow researchers from Brigham and Women’s Hospital and Harvard University in Boston. This scale is similar, she says, ranging from no symptoms in stage one to symptoms at rest in stage four.
Another tip is to standardize all patient educational material. Take a look at what a lot of patients are getting, Carlson says, and not only will you find they get it from many different sources, but often the information varies. An example is knowing when to call for a weight gain. One pamphlet may say to call when a patient is two pounds heavier. But another brochure says do it at three pounds, and a fact sheet may give the instruction for a five-pound gain. That gets confusing, and the patient often does nothing but throw it all in the trash. No prepared materials suited Sharp’s needs, Carlson says, so the staff created their own, keeping in mind reading levels and large-size print for readability.
The study is finished at one site and winding up in the other two. The staff then wants to publish a report in a peer-reviewed journal. Carlson says Sharp plans to study how to help patients with impaired cognitive skills — something many other studies exclude from their scope.