Program to reverse heart disease shows 76% reduction in hospital stays

Case managers are glue that holds the program together

At Highmark Blue Cross Blue Shield, case managers are a vital component of the company’s Dr. Dean Ornish Program for Reversing Heart Disease.

"The case manager is the glue that holds the multidisciplinary program and the team together," says Janet Banaszak, RN, CCM, national psychiatric consultant and director of case management.

The Ornish program involves lifestyle modifications designed to benefit people who have coronary artery disease or are at risk for developing it.

A multidisciplinary team works with participants on four components of the program: exercise, stress management, group support, and diet.

"The nurse case managers really support the patients. Their role is to monitor their medical status at all times, assess their progress, and work with them to determine what they need to do to be successful," Banaszak says.

In the two-year follow-up period after they have completed the program, Ornish participants have achieved a 76% reduction in hospital stays for cardiac events.

The Ornish group experienced an 87% reduction in myocardial infarctions compared to a 48% increase for a matched control group. Similar findings were documented among Ornish participants for angioplasty (down 84%), bypass surgery (down 80%), angina (down 78%), and cardiac catheterization (down 64%).

"We follow the patients for two years and find better results during the second year. The longer they stay on the program, the more benefit they get," Banaszak says.

Here are some of the other outcomes:

  • Participants lost an average of 11 pounds.
  • Their systolic blood pressure dropped by 9.7. Diastolic blood pressure decreased by 6.4.
  • Cholesterol levels decreased by 13%.
  • Depression scores dropped by 44%.

Highmark became the first insurer to provide and pay for the program for its members at the behest of Anna Silberman, a company vice president who was convinced that the program could help Highmark members take control of their own health.

"Highmark has always been on the forefront of wellness. Representatives of the company spoke to Dr. Ornish and studied the research and concluded that the program was a very conservative and non-invasive way to make significant health strides," she says.

At first, the insurer offered the program only at its Pittsburgh headquarters, but the initial outcomes were so impressive, Highmark expanded it to other states. The company now offers the program at 16 sites in Pennsylvania, West Virginia, and Illinois, and will begin offering the program in Minnesota this year.

In most cases, several insurers work together with a local hospital to offer the program.

Highmark’s Ornish program was cited for its valuable clinically based outcome data and efficacy in 2003 at the annual "Best of Blue" National Awards for Innovations and Best Practices in Medical and Pharmacy Management.

The program also was recognized in the first BlueWorks Quarterly Report, a collaboration between Blue Cross and Blue Shield and Harvard Medical School researchers to highlight innovative partnerships with health care professionals.

The program targets members who are contemplating bypass surgery or angioplasty but would like alternative options; members who have had one or more heart procedures; members diagnosed with coronary artery disease; members who have significant risk factors for developing cardiovascular disease, such as high serum cholesterol levels and a strong family history of heart disease; and members who have diabetes.

Patients may be referred by physicians, by self-referral, or by case managers or other staff within Highmark.

Members who don’t meet the criteria but still are interested in the program may self-pay.

When a member expresses an interest in the program or is referred, he or she receives a health assessment questionnaire in the mail.

"We screen the members carefully to make sure they meet the criteria and to get an overall idea of their general health to make sure they’re able to do the program. The exercise component is moderate, but we want to make sure they can complete it," Banaszak says.

When a member is identified as eligible for the program or expresses an interest in joining it, the nurse case manager usually is the first person to whom they talk. The case manager interviews the members, takes a health history, and helps them decide if the program will be appropriate for them.

Members who sign up for the Ornish program attend sessions four hours a day, twice a week for 12 weeks, usually at a local hospital that partners with the insurer to offer the program.

The nurse case managers accompany the patients through the entire program.

"The nurse case manager role is vital. There is some research that suggests a relationship between outcomes and the nurse case manager. Studies have shown that a nurse case manager can decrease the number of hospital admissions, decrease length of stay, and decrease the number of emergency room visits," Banaszak says.

Members receive a psychosocial screening when they join the program, after 12 weeks, and after one year. "We see wonderful results from the psychosocial screening. After the first 12 weeks, there’s an improvement in depression, decreased hostility, and improved quality of life," she reports.

Members with significant psychosocial issues are referred for treatment before they enter the program.

The case managers typically work with about 50 patients at a time. Usually about 15 members attend the biweekly sessions. The rest have completed the program.

All of the team members undergo extensive training that helps them understand how the program works, their role, and the role of the other team members.

In the Ornish program, all of the team members chart on their specific modality. The nurse case manager coordinates the documentation and makes sure the other team members are completing their documentation.

The nurse case manager’s main role is the safety of the patients. They constantly assess to make sure they are doing well and talk to them every time they come in.

Patients are asked to fill out a personal adherence log, which the case manager checks to make sure they are following the program at home.

If a patient reports any changes in his or her health, such as having angina or feeling that something isn’t right, the nurse case manager either gets in touch with the referring physician or takes the member to see the program’s medical director.

Banaszak gets in touch with the patients’ primary care physicians on a regular basis and lets them know how the patients are doing, sending regular outcomes and progress reports.

"This is a treatment option that does not replace the physician. We work closely with the patients’ personal physicians," she says.

Because the program involves such dramatic lifestyle changes, Highmark uses a rigorous screening process to make sure the patients will stay in the program once they enroll.

"We are very clear during the initial interview about what is involved in the Ornish program. The idea is to let them know up front what they will have to do and the benefits of it," Banaszak says.

Patients feel better within the first two weeks of the program, experience a decrease in angina, and lose weight, she notes.

"They start to feel better about themselves, and that is a strong motivator to keep them going," Banaszak adds.