Focus on Outsourcing

Outsourcing cuts costs, keeps patients smiling

Systems emphasize education, follow-up

If you are not yet outsourcing your patients with congestive heart failure (CHF) or cardiovascular disease, you have a few options to consider. Utilizing one of the several services available could save your facility money and improve clinical outcomes at the same time by drastically reducing admissions and emergency department (ED) visits. The key factor shared by home-based systems for managing these patients is frequent nursing contact — in-person and by telephone.

In the three years the program been offered, MULTIFIT, licensed by Buffalo Grove, IL-based Cardiac Solutions, has reduced hospitalization rates by 87%, ED visits by 67%, and cardiology visits by 31% among 51 heart failure patients hospitalized at a northern California Kaiser Permanente medical center.1 The patients’ functional status improved significantly, and symptoms improved.

In another population of patients — about 2,000 members of Humana, a large managed care organization in Louisville, KY — inpatient hospital days, admissions declined by 58%, and ED visits were cut in half.2

The patients at Humana had New York Heart Association (NYHA) Class III and IV failure; 90% maintained or improved their classification while under the care of MULTIFIT. The patients had a 15% overall improvement in functional status, and a 10% mortality rate as compared to the national average of 24%. In addition, sodium intake declined by a fifth. Total hospital expenditures were reduced by 62%, and there was a 78% reduction in CHF-related costs.

Like other CHF management programs, Multifit has such good results because it addresses the key issues that are known to contribute to the exacerbation of heart failure:

• suboptimal utilization of medications such as angiotensin-converting enzyme (ACE) inhibitors;

• poor adherence to sodium restrictions and pharmacologic therapy;

• inconsistent post-hospitalization follow-up and symptom identification.

The outsourcing system employs nurse managers with a minimum of five years of cardiac experience and ensure that they are supervised by physicians. Nurses work individually with patients and help them manage their symptoms in the home environment. After an initial in-home visit, the nurses work with patients mostly by telephone. When a situation warrants, the program is set up to call on contracted local "nursing partners" to make additional home visits.

The protocols of MULTIFIT and other disease management programs are based on national guidelines for the care of patients with left ventricular systolic dysfunction from the Agency for Health Care Policy and Research and the American Heart Association.

The guidelines often fail in clinical practice, experts say, because no one has the specific responsibility of making sure they’re implemented and logistic problems that include little time for individual patient-physician contact. Outsourcing systems solve those problems by employing nurse managers who evaluate each patient’s treatment plan and medications to make sure they follow the guidelines. If guidelines and true treatments don’t match, the managers point out the discrepancies to the physician and determine changes to be made.

After initial assessment, a care plan is developed including pharmacologic and lab management, symptom triage, patient contact schedules, and lifestyle management. Typically, patients are placed on optimal doses of ACE inhibitors. In the study above, the number of patients who received target doses of lisinopril increased by 82%.

Besides providing a check-and-balance, outsourcing systems provide good decision-making by competent nurses at a cost lower than physicians would charge. And there is less hassle for physicians.

"Physicians love it," says John Roglieri, MD, medical director of NYLCare Health Plans of New York (NY). "We get the patients off their backs. We tell them when a patient’s getting into trouble. The patients wait for our phone call instead of theirs. Every physician needs an extra pair of hands and an extra pair of ears, and that’s what we’re giving them."

It is hard for many patients with CHF or other chronic cardiovascular disease to stay on the straight and narrow, and an outsourcing system provides something akin to a support group to decrease patients’ potential to stray. Nurses provide patient education and support.

After the initial home visit and case conference with the physician to assess the patient’s situation and needs, the nurse begins regular contact with the patient by telephone. Patients are called weekly, then monthly as their conditions improve. The nurses follow a scripted format for the calls, asking a series of questions and entering the responses into a database. They also discuss a specific educational topic with the patient each call.

The results of the phone conversations are reported to the physician along with results of written questionnaires patients complete four times a year. The provider sees reports on clinical indicators such as functional status, sodium intake, and medication compliance as well as utilization data on hospital admissions, ED visits, and any procedures. Progress reports are submitted to the patients as well. Seeing their improvement on paper is a good motivator for patients. If patients know someone is watching their sodium intake, for example, they’re much more likely to watch their diet.

Triage is available 24 hours a day, seven days a week. If a situation arises that warrants a personal visit, a home health nurse is dispatched. He or she may perform emergency treatments such as IV diuresis if the physician directs. Home visits also may be done periodically for elderly patients in cases where it is important to see the home environment, the medications being taken, and meals being prepared.

Another disease-management program has resulted in a decrease in hospital admissions and a significant improvement in quality of life for CHF patients, according to a new outcomes study of 149 patients, conducted by Stuart Disease Management Services of Wilmington, DE.3

The goal of the Stuart program was to reduce hospital admission and readmission rates, length of stay, total hospital days, and ED utilization. Prior to the outcomes study, only 23% of patients had been getting appropriate drugs to control CHF; and 72% of hospital admissions for patients age 65 and older were a result of complications associated with CHF.

After one year, the number of patients receiving drugs doubled, and hospital admissions for CHF decreased by 83%. Patients enrolled in the program also reported a 44% improvement in quality of life, including improved health and new personal relationships with telemonitoring nurses.


1. West JA, Miller NH, Parker KM, et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol 1997; 79:58-63.

2. Burns J. Talk the talk and walk the walk. Managed Healthcare 1997; August.

3. Roglieri JL, Futterman R, McDonough KL, et al. A look at heart failure utilization before and after the implementation of a disease management program. Am J Man Care 1997; 3:1,831-1,839.