HF study readies agency for PPS, capitation

As VNS of New York, the largest freestanding, nonprofit home care agency in the United States, looked toward the future in 1997, management saw several things of importance.

First was the move toward capitated contracts that would leave the agency at risk for patients who were rehospitalized or whose care otherwise departed from accepted norms. The other issue staring the agency in the face were the interim and prospective payment systems that would require the agency to do more and better while reducing utilization.

Ultimately, when the agency paired up with Lenox Hill Hospital in New York City for a joint disease management (DM) study in 1997, it seemed an opportune time to put together programs that would address those issues, says Maureen Dailey, RN, MSN, CETN, director of the Centers of Excellence and Disease Management for the 1,500-nurse agency. The result was a DM program piloted from a joint United Hospital-funded study for heart failure (HF). Among the positive results: reduced rehospitalization rates, improved patient satisfaction, and the integration of available state of the art technology at VNS and the hospital. There is also some anecdotal evidence that nurse and physician satisfaction has improved.

Electronic intervention

As an example of how well the program can work, Dailey points to an 86-year-old man with HF and a new diagnosis for pulmonary fibrosis, and new to home oxygen use. He lived alone and had been rehospitalized six times over a two-year period — at a cost of about $5,500 per hospitalization. Dailey says the patient often failed to monitor his weight daily and fell out of the weight parameters set by his physician — sometimes precipitated by eating high-sodium foods.

Under the new program, he was put on electronic monitoring through which his daily weight check and other vital statistics were automatically sent to the VNS office. Through biofeedback, education, and coaching by his home care nurse, he began to understand the link between his weight and related changes in his cardiac health status, and the need to intervene before the need for hospitalization arose.

If the patient failed to complete a weight check or if his weight went up too much, he was phoned by a nurse and encouraged to take action. At one point, after aide visits stopped, he put on five pounds.

"As it turned out, the patient ordered in high-sodium, prepared kosher food when the home health aide was discontinued," says Dailey. "During holiday periods, he also ate high-sodium foods. The physician was notified, his medications adjusted, and a nurse went in and educated him about the salt content of prepared kosher foods he was ordering into the home."

The nurse taught him about "programmed cheating" for occasional times the patient knew in advance that his salt intake would increase. She told him that if he knew there was a situation where he might stray from his prescribed regimen, he should call his physician and negotiate some extra diuretics. "Assessing individual patient preferences and cultural influences is important to include in the nursing assessment," says Dailey, noting that the VNS’ culturally sensitive and literacy-appropriate patient Heart Failure Self-Care Guide was used in the study across the continuum of care.

"The monitor gave us real time clinical data so that early and effective intervention could prevent avoidable rehospitalizations until the patient was independent in effective self care. That patient hasn’t been back in the hospital for almost two years," she says.

Using technology to improve outcomes

The program starts in the hospital, where HF patients must achieve specific outcomes in order to move through various phases of the program. The focus is on wellness, not days spent in the hospital. A nurse case manager follows the patients throughout their stay at Lenox Hill, coordinating care and intervening when the need arises. They also ensure that home care is available when necessary after discharge, working with the VNS home health intake coordinator (HHIC).

Once in the home care program, patients are started on a comprehensive care management program that includes monitoring daily weights and blood pressure. For high-risk patients, such as those who have a history of more than one rehospitalization in the last year, a telehealth monitor is provided for the patient. It monitors weight, blood pressure, pulse, and blood oxygen levels, transmitting them to a central station.

Dailey says the monitoring is important during the first week or two following discharge for high-risk patients, augmenting clinical data assessed on home visits. "The transition zone from acute care to home care can be a vulnerable time for rehospitalization," she says. Patients being weaned off of home care are also monitored electronically when they are otherwise identified as high-risk patients. Not only does this automatically alert staff to any problems early, but patients like the 86-year-old man can receive positive reinforcement of desired behavior via biofeedback.

The HHIC’s electronically transmitted a heart failure protocol in the patient plan of care to the home care nurse. The protocol cues the nurse to use patient self-care guides and best practice tools in care management. The protocol includes key clinical information communicated from the patient’s acute care stay. The cardiopulmonary clinical nurse specialist from VNS educated the home care staff about best practices and the heart failure pathway. The HHICs were also coached about what vital information to include in the protocol section — such as weight and blood pressure parameters, the ejection faction, and the New York Heart Association functional classification.

A VNS clinical specialist is available to consult on particularly complex cases, and because of the electronic components of the program, the notes from that specialist are electronically available to any nurse caring for that patient via the electronic record.

The outcomes from the program were strong: Along with a reduction in 30- and 90-day readmission rates to 20% compared with a national average for Medicare patients of 50%, 86% of the patients that were part of the program were put on ACE Inhibitors, compared to a national average of just 40%. Dailey says those patients with more than one previous rehospitalization fared even better, with a reduction of 50% in readmission rates.

VNS found some other benefits to the program too. For instance, Dailey says that ejection faction is not the most significant predictor of rehospitalization among all populations. "That was interesting. That was good information for us, and we have to be aware that we may not be able to generalize to all patients what we learn in a particular study. Each population must be stratified according to significant risk factors for that population."

Dailey also says that VNS was able to capitalize on other opportunities for improving care management by taking what they learned in this study and applying it in other situations. For example, all HHICs in every hospital are entering specific heart failure information into the patient record to improve communication of key clinical information across the continuum of care.

Expanding success

While the program originally started only with Lenox Hill patients, its success has led VNS to expand the program to all of its hospital referral sources. "All our nurses have been educated to this now," Dailey says. "All HHICs have been educated to the key information that is needed in the plan of care specific to heart failure. We have demonstrated that this information is important to quality of care."

The success across regions and teams is still being studied and the model perfected, she adds, but so far, patient satisfaction rates are high; staff has verbalized satisfaction with the integration of best practices for heart failure; and rehospitalization rates are down for HF throughout the agency.

"You can conceptualize disease management as having four pillars," Dailey says. First, there is there is population stratification that helps identify who in the HF population needs management. Second, there are clear guidelines on the disease — in this case, from the Agency for Health Care Policy and Research. Thirdly, there is aggressive early management that allows an agency to respond quickly to changes in the patient’s clinical status on a multidisciplinary basis. And lastly, there is outcomes tracking, which looks at clinical quality, satisfaction (patient, physician, and nurse), patient quality of life, and cost.

"Through this program, we gained experience in these four pillars," says Dailey. "We were also able to see not just how it affected our cost, but how we could use information on cost across the continuum of care to help us build a cost effectiveness model across the continuum of care. As we move to capitated contracts, this will help. We can go to our payers and say that spending more money on a comprehensive disease management program involves more outpatient costs. But overall costs are down when avoidable rehospitalizations are prevented."

Dailey emphasizes that HF rehospitalizations aren’t just a cost indicator, but a key clinical quality indicator, since research has demonstrated that HF patients have significant morbidity and mortality with rehospitalizations.

She says that if you can align your incentives with those of other providers, you are doing everyone — including patients — a favor.

"We have a close relationship with Lenox Hill due to our joint venture in home care and providing outsourced cases management services to the hospital for acute care in 1999. Through that close relationship, we can easily replicate the model we tested in the UHF study. In addition, we are taking what we have learned and working collaboratively on continuum care pathways with other acute care customers," she says. "The more we can collaborate with other care partners, the better care outcomes will be for all our patients."

Effective DM programs will ensure home care agencies’ success in the future, Dailey says. "We have many customers; through this model for high-volume high-cost diagnosis like HF, we will partner with referring customers to improve the continuum of care. Disease management is an excellent model to take exquisite care of whole populations of patients one person at a time. You can’t just have good case management. Seamless integrated care is the new standard." n


Maureen Dailey, RN, MSN, CETN, Director of the Centers of Excellence and Disease Management, VNS of New York, 107 E. 70th St., Fourth Floor, New York, NY 10021. Telephone: (212) 794-6636.