A phone call a week cut costs by $800 per patient

CHF program tracks three indicators

The outcomes for the Heart Failure Program at University Health Systems of Eastern Carolina in Greenville, NC, are astounding. The cost to the health care facility for 12 patients tracked during the first six months dropped from $3,300 per patient to $2,500 post-program. The Heart Failure Program, launched in October 1998, currently has 75 enrollees. More data will become available each month as more and more patients are involved long enough to track.

To determine the effectiveness of the program, three outcomes are analyzed, according to Susan Ingram, BSN, program coordinator. These include the number of admissions pre- and post-program, the average length of stay (LOS), and cost per patient. The 12 patients tracked were admitted to the hospital a total of 19 times before they were enrolled, and only five times post-program. Their average LOS dropped as well, from 3.4 days to 2.6 days.

"The basis of this system is to provide patients with a program that is aimed at self-management. The cornerstones of the program are intensive patient education and continuous outpatient case management," says Ingram.

There are a number of inpatient and outpatient strategies that affect the outcomes, she explains. When patients are referred to the program, Ingram evaluates them to establish a baseline. She asks a series of lifestyle questions to determine some of the dynamics that will play a role in patients’ ability to comply, such as whether they are living alone, are hard of hearing, or speak little English. About 85% of program enrollees are inpatient referrals.

The evaluation also helps her determine the extremity of the heart failure, such as whether patients must sleep with three pillows or if they are short of breath at rest or with minimal exercise. The information helps her to determine whom she needs to incorporate into the teaching. For example, if someone plans and prepares the patient’s meals, that person will need to be included in the education so that he or she understands the patient’s diet.

At the consultation, the initial teaching is provided, unless a caregiver needs to be included. In that case, the teaching is scheduled for a later date. During the session, patients learn how a normal heart functions and how differently an abnormal heart functions. They also learn about their medications; the importance of adhering to a low-sodium diet, exercise, and weight management; and symptom management. Patients receive a booklet containing the information for future referral and a pocket diary that has the warning signs of heart failure, a calendar to track weight gain, and helpful compliance reminders.

Behavioral modification used in phone calls

While the initial teaching session introduces patients to the four areas they must concentrate on in order to control their heart failure symptoms, behavior change takes place over time as patients work with Ingram via the telephone. During the phone call, Ingram doesn’t just go over the information; she works with patients until they understand how to apply the lessons. For example, she helped one patient create a low-sodium menu for one week. Patients are encouraged to call her as well — and they do. One patient called to ask for help in interpreting the label on a canned food product.

"The success of the program is after the patient has gone home. I am doing phone compliance and behavioral modification over the phone. I am going through a questionnaire that speaks specifically about weight monitoring and exercise, symptom management, low-sodium diet, and medication compliance. I talk to these patients weekly," says Ingram. (For details on the telephone interview, see story, p. 44.)

During the initial evaluation, patients are entered in either phase one or phase two of the program. Those who understand heart failure and what type of exercise and diet they need to adhere to and are doing a good job controlling symptoms are placed in phase one. Those patients receive a phone call once a month. The phase two patients are called weekly. Patients who have had multiple hospital admissions are automatically enrolled in phase two. The initial telephone call usually takes place two to three days after discharge.

To keep track of calls, Ingram keeps a spreadsheet that helps her quickly identify who needs a phone call. About 99% of the referrals are initially enrolled into phase two of the program. After eight to 16 calls, most are moved into phase one and receive monthly follow-up calls. There is no time limit on the program.

In addition to the Heart Failure Program, Un i versity Health Systems of Eastern Carolina has implemented a care path for patients with heart failure that is followed when patients are admitted to the hospital. A complementary home health care path was created to proceed with the continuum of care.

The key to the program has been in helping patients find ways to comply so they can better manage their heart failure, says Ingram. "I think the follow-up phone calls are definitely the catalyst for changing their behaviors," she says.