Telephone system supports daily routine
Telephone system supports daily routine
Doctors get helpful patient feedback
Can a one-minute routine each day, every day, make a difference in keeping your CHF patients out of trouble?
An Illinois CHF team says, "Yes." Four years ago, staff of the CHF Tel-Assurance program in Northfield devised an automated telephone system that structures such a routine that begins after patients record their morning weight. They phone in their results and answer six yes/no questions about how they feel.
A computer analyzes the responses, and potential problems are reported to the right physician. During the testing phase of the system, researchers found CHF hospitalizations were cut by more than 60%. Today, the service is now offered to many different health systems in several states.
The service fills a gap in how most CHF patients are treated today, says cardiologist Randy Williams, MD, director of CHF Disease Management for Evanston (IL) Northwestern Healthcare. Williams and a team of caregivers developed and tested Tel-Assurance at his facility.
Even if treatment is right on target for a particular CHF patient, Williams says, there traditionally hasn’t been a feedback loop that lets the doctor see how the patient is doing.
"The patients walk out the door and everyone assumes they will follow all the education and instructions," he adds, "but there are three key things that remain unknown."
Williams says these three unknowns fit into basic questions about each individual patient being treated for CHF:
ª Is the patient learning about the disease, medication, and treatment strategy?
ª Is the patient following the treatment strategy?
ª Are both the treatment strategy and education helping the patient?
Williams says that too often, doctors learn that some of the answers to these questions may have been "no" for days or weeks — but the doctor doesn’t find out until the patient’s status is out of control and requires hospitalization. Even then, once a patient is discharged, often there is no structured way to keep up with the patient to head off problems before they develop into a serious situation again.
Tel-Assurance works, says clinical operations director Patricia Kentgen, RN, because it records the status of each participating CHF patient on a daily basis and lets the caregivers know who may be headed for trouble within the first 24 hours of weight gain or worsening symptoms. Doctors can then get back to those patients quickly to change prescription dosages or address other problems. "That information creates a safety net," she says.
Williams and Kentgen say the daily call takes an average of 40 seconds to a minute. Callers first enter their Social Security number and hear a recorded voice confirm their name and their doctor’s name. Any messages the doctor has left for the patient will be given.
Then it’s on to the questions, which are all in a yes-or-no format. One button on the touch-tone telephone corresponds to a yes-or-no response. Patients respond to the questions and record how they feel compared to the previous day:
ª Compared to 24 hours ago, are you experiencing more shortness of breath?
ª Did you wake up last night with shortness of breath?
ª Did you need to use an additional pillow or have to sit upright in order to be able to rest?
ª Have you needed to rest more in the last 24 hours?
ª Are you experiencing lightheadedness or dizziness?
ª Are you experiencing more swelling?
Patients then enter their weight, which will be compared to the target value for that person. A recorded voice confirms the entry — to make sure patients are not reporting they now weigh 475 pounds, when it should have been 175.
Keeping it brief
After the weight is recorded, the callers can hang up and go on with their day. "The questions can vary somewhat, but our belief is if you can know the answers to these question every day, you can manage the disease and keep patients out of the hospital," Kentgen says. But the list must remain short.
"Our concern with keeping patients on the phone any longer than necessary is that they will lose interest," she says.
Kentgen notes many studies looking at patients with diabetes reported a common sentiment that affects compliance: The more time caregivers made them spend managing their disease, the less likely it would be done. "Patients often expressed feelings like I don’t want to spend any more time on my disease than I am right now.’"
The basic call takes about a minute, but if patients want to stay on the line longer, they can access educational messages and request that copies of the material are mailed to their home. Also, if patients are in trouble, their calls are transferred to a nurse on duty.
The system takes calls from 5 a.m. to 11 a.m. The recorded information is analyzed for variance from an initial profile made for each patient according to an enrollment sheet filled out by the treating physician. (See sample enrollment sheet, inserted in this issue.) If there are any deviations from the target profile, the system sends a report to the appropriate doctor through fax or e-mail.
"The doctor only gets a report when it’s different from the conditions on the enrollment sheet," says Kentgen. So if there are 100 patients in the system, the doctor will not get a report on everyone every day.
Doctors would have to wade through a deluge of messages just to find the ones that contain what Kentgen calls "actionable information." She notes the tests that used Williams’ facility as the beta site found on any one day, a report is sent to the physician for about 15% to 20% of the total number of a doctor’s CHF patients participating in the service.
The physician factor
"There definitely is a physician education [component] to this," Kentgen says, noting patients do best with the service when the program has physician buy-in. It helps when doctors realize they will not be getting a report from every CHF patient every day.
Williams notes, however, some may have to change their concept of the dynamics of the disease. The daily monitoring means caregivers are setting tight parameters of how well the patient can breathe, get around, and avoid weight gain.
"You don’t need to tolerate much fluctuation at all," Williams says. He adds that with the patient’s weight, tight management is not allowing a change of more than one or two pounds. "We’re able to pick it up so early," he says.
Doctors then need to develop systems of how to respond to the reports they get on the patients who are falling from their recommended guidelines, or those who are not calling in to give their reports.
Ideally, Williams says, doctors can get back to the patients with a phone call to instruct them on what they should do with the diuretic or other medication. But there will not be the same amount of attentiveness among doctors who get the reports. When the doctor is filling out the one-page Tel-Assurance enrollment form for the patient, that’s a good time to consider how to respond when the patient status deviates from the registered conditions.
Kentgen and Williams say other elements of this system draw on experiences quite familiar to most doctors. "Physicians are very accustomed to getting results and data every day and using them to make decisions. This is no different," Kentgen says.
Williams adds Tel-Assurance is based on patient behaviors that many doctors probably have noted themselves. Consider randomized clinical trials, for example, where researchers have compared the results of treatment with a drug vs. a control.
The studies have to be designed so patients are closely followed — whether they end up getting either the drug or a placebo. Often, the studies are conducted at large transplantation centers where nurses can track the course of therapy and what participants experience.
In these clinical trials, Williams says, the placebo group often does better than what would be expected with a similar patient being treated at large. The difference is having a system of monitoring the patients and keeping them involved in the study.
"There’s something about that contact, that frequency of oversight," he says.
This observation comes as no surprise to industrial engineers as well, Williams says. In their circles, it’s called the Hawthorn Principle: If workers make widgets on an assembly line, the quality of the product depends on how well each worker performs his or her task along the production. So management monitors the workers as they perform their part of the process, and quality along the way improves.
Further, it should be no surprise to doctors that all patients have difficulty with the day-to-day aspects of their conditions such as eating right, taking medications properly, and getting exercise — whether they have CHF or not. Add the fact that these patients have that condition, and "You have a tough group of people to handle."
Following the CHF regimen is a lot like brushing your teeth everyday, he says. Chances are good mom had to nag you to do it until the habit became ingrained. Whether it is children brushing their teeth or those patients in the clinical trial who get the placebo and still do better than would be expected, there’s a lot to be said for that level of routine reinforcement.
"What we did is apply it to health care," Williams says. In a system test, Williams took 100 CHF patients that came through his hospital and provided the service. Patients ranged in CHF severity from NYHA class II to IV. Compliance ran about 90%. After patients are enrolled in the program, a nurse guides each participant through the first phone call.
Gradually, Kentgen says, they learn more than the routine; they learn to associate their symptoms of a particular morning with what they did the previous day, like eating too much salt or missing a dose of diuretic or other medication. This teaches the patients about the consequences of not following their routines.
Kentgen adds that it’s common for patients to avoid calling their doctor when they have problems because they don’t want to feel they are bothering their physicians or taking them away from their other patients. With this system, if a patient is calling in a daily report without triggering a call back, he or she can feel reassured that all is well.
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