Good case management controls CHF comorbidities

Treat comorbidities and CHF

By taking an innovative approach to the treatment of comorbidities in elderly congestive heart failure (CHF) patients and by tracking those patients throughout the continuum of care, disease managers at Good Samaritan Hospital in Lebanon, PA, have reaped significant benefits — both for their patients and for their bottom line.

"We always felt that we had done such a good job educating our CHF patients at the time of discharge, but we found out that there were many things that we were totally missing," says Jeanne Donlevy, RN, senior vice president of patient services at Good Samaritan, which is licensed for 190 beds. "We never would have known that if we hadn’t started working directly with patients in the home care setting."

Cross-train RNs to make home visits

The idea was to cross-train nurses to perform home care visits to elderly CHF patients and to track those patients’ progress in the home environment. "You have to find a way to provide ongoing monitoring and support because the elderly really do need that," says Donlevy. "Many of them live alone, or they don’t know how to reach out for help. And the more that you provide this kind of support, the more you ultimately save health care dollars because there’s less utilization of the health care system."

As a result of their efforts, disease managers at Good Samaritan have seen marked declines in readmission rates for CHF patients. In 1992, the hospital’s readmission rate within 31 days was 10.8% for CHF. By 1995, that rate had dropped to 0.9%, Donlevy reports.

Whereas younger CHF patients tend to have more severe problems and tend to be potential candidates for heart transplants, the treatment of elderly CHF patients is often complicated by a host of comorbid conditions, says Barry Baines, MD, associate medical director of HealthPartners, a Minneapolis-based health plan with 695,000 HMO and PPO members. A proper understanding of the effect of various comorbidities is crucial to the proper treatment of these patients, Baines adds, especially considering that CHF incidence rates among patients in their 80s run as high as 10% to 15%. (See related story, p. 48.)

"The older patients get, the more likely they are to have a functional impairment or have co-morbidities like diabetes, arthritis, or Alzheimer’s," says Baines. "Those kinds of things tend to make the elderly population generally more complex. Not so much because of the actual intensity of the disease but because of the comorbidities that make it more complicated."

One area in which complications can easily arise is medication, says Donlevy. For example, certain drugs typically prescribed to CHF patients could be toxic to the kidneys of a patient also suffering from end-stage renal failure. Similarly, drugs designed to treat renal failure "might in fact not be the best from a coronary standpoint," says Donlevy.

Tailor patient education, treatment

As a result of the possibility of complications for patients with comorbidities, it’s crucial that you tailor your education and treatment of the patient to the comorbidities as much as to the CHF, stresses Vivian Mayopoulos, RN, BSN, medical program manager and cardiac case manager at Good Samaritan Hospital.

Because of the particular difficulties presented by patients with both CHF and renal disease, Good Samaritan is in the first stages of developing a CHF/renal failure critical pathway specifically to address this comorbidity.

The presence of comorbidities in elderly CHF patients also underscores the need for aggressive, centralized case management, says Donlevy. "It really does take someone who is overseeing these people very closely. That’s why they’ve gotten into problems in the past — because they have such a delicate balance as to what is or isn’t enough fluid. If they’re not watched by someone who really knows a lot of the little tricks, they can get into a great deal of trouble. And in most situations, I don’t think there are programs in place like we have where they’ve got someone following patients in the home and in physicians’ offices the way we do."

Every day, Mayopoulos reviews information and stay sheets on all of her CHF patients who entered the hospital during the previous 24 hours. She also reviews the emergency department log, to see if any of her patients have come into the ER and gone home overnight. "Recently, I had a patient who’d come into the ER two Monday evenings in a row, so I met with him to see what he was doing differently, to have those episodes of failure," says Mayopoulos.

She visits all the CHF patients in the hospital on a daily basis "just to see how they’re doing, what their clinical status is, as well as the qualitative piece of it — how are they feeling about their disease and ongoing education, so that my goal as well as theirs is to get them back into their home environment where they can have some quality to their life."

When patients do go home, a group of visiting nurses called the Congestive Heart Failure Team make home visits to perform cardiopulmonary assessments and make sure patients are weighing themselves daily and watching their diet. Mayopoulos considers Good Samaritan’s degree of follow-up and monitoring the key factor in the hospital’s dramatic reduction in readmission rates.

"I really am proud that we started this program," says Donlevy. "It’s a different kind of model environment, and it’s one that has really helped us to face where we’re going in the future, which I strongly feel is having support for these high-risk patient populations. That’s the only way that we’re going to get the health care dollars that are being spent down. It’s really in providing preventive services, ongoing support, and a mechanism that gives patients in these high-risk diagnoses some way of following up with a health care provider for the support that they do need."