Try the big three in time management

Bring a balance to your management style

Do you have enough time to assess the health, medication needs, mental status, disease progression, test results and everything else pertaining to each one of your patients? The balance of seeing enough patients to run a successful practice while making sure each one still gets quality time makes for tight schedules, to say the least.

CHF Disease Management talked to physicians about time management techniques in treating CHF. Their responses fall into three major categories:

Involve yourself according to your expertise

Managing patients with CHF is literally a cardiology subspecialty now, says Gordon A. Ewy, MD, chief of cardiology at the University of Arizona Health Sciences Center and director of the Sarver Heart Center, both in Tucson. Besides being familiar with drug therapy, he says, the CHF manager needs to be able to:

¤ look for hibernating myocardium produced by fast heart rates;

¤ know that systolic and diastolic dysfunction may differ;

¤ conduct quick tests to know chronic CHF is present, such as the hepato-jugular reflex.

Examining patients for symptoms such as rales or checking chest X-rays may not be helpful since those are mostly signs of acute disease. (See related box for details on this test, p. 4.)

"There’s no way a primary care physician with 10 to 15 minutes can manage this disease correctly," he says. "I can’t even pick out a pair of socks that quickly." He notes that he needs to spend an hour with a new patient and usually 30 minutes for a follow-up appointment.

Unless generalists have a particular interest in CHF, Ewy says, they need to focus on preventing CHF and catching existing cases as soon as possible. "The generalist’s role is to do things like aggressively treat cholesterol and to make sure systolic pressure is below 120 and diastolic is under 90." Once patients show signs of decreased ventricular function, he says, it’s time to step up cardiac care and bring in the specialists.

Focus on the tasks only the doctor can do

"The key is through the judicious use of physician extenders," says William T. Abraham, MD, director of the heart failure and cardiac transplantation section at the University of Cincinnati College of Medicine.

"The catch phrase is a multidisciplinary team approach," he says. "Bring in dietitians, nurse specialists, and pharmacists for taking care of patients." Those people can do the bulk of patient education. "The doctor can do a brief directed exam and then see to making treatment decisions and reinforce what the patients get from the other team members." That way, Abraham says, patients keep hearing messages such as, "Cut down on salt," because they are repeated by several different people.

Deputize a telephone staff

"A lot of smart people say if we call people every day and tell them to take their medication and to avoid the salt shaker, your chance of keeping them out of the hospital is better than if you say I’ll see you next month,’" says Richard Pozen, MD, national medical director of Vivra Heart Services in Fort Lauderdale, FL, and its HeartAssist CHF disease management program.

At its simplest, a telemanagement program can be handled by one person armed with a list of questions and some direction from the office medical staff. Phoners call patients on a regular basis, record how they are following instructions and report any red flags to the physicians who can take action. At the other extreme, outside contractors can be hired to connect patients with a network of nurses to assess, educate and activate emergency response protocols as needed. Somewhere in the middle of these two extremes, individual practices can get their nurses and other trained staff to form a telephoning system. (See related article on forming your own telemanagement system, at right.)

"If you have a nurse practitioner, a physician’s assistant, or even a good receptionist who is good on the phone, have them call — patients love it," Pozen says.

Abraham says whoever works the phones should be both proactive and reactive. That is, they initiate regular calls to head-off problems and have a system of dealing with the things they discover. This brings in the physicians when they are needed, while delegating other duties that do not require direct physician involvement.