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Since South Weymout, MA-based Harbor Medical Associates began its disease management program for congestive heart failure (CHF) patients, hospital admission rates and visits to the emergency room have decreased dramatically for the 3,000 Medicare risk patients in the program, says Hilja Bilodeau, RN, CCM, director of case management.
The disease management program is a partnership among the medical practice, CVS Health Connections, and Pfizer Health Solutions.
Here’s how the program works:
The physician practice’s case management staff identified the initial patients for the program by examining ICD-9 codes.
Subsequent patients have been identified by their primary care physician or the hospital staff.
If a patient is admitted to the hospital for the first time with a diagnosis of CHF, the case managers are notified immediately and are able to speak to the primary care physician and the family about putting the patient in the program.
"A lot of times we have the opportunity to interface with the family early on and establish expectations right away," she says.
When the patients’ physician approves their participation in the program, the staff invite them in for a 90-minute visit at the CVS Center for Wellness education, located in the same building as the medical group’s main office.
They are assessed by the nurse practitioner, who collects baseline information on their health status. The nurse practitioner and pharmacist review the patient’s medication and work with the physician office case manager to develop a care plan that is submitted to the physician for approval.
"We make sure the patients receive every opportunity they can for quality medical care and that they are getting everything that can be provided for them," Bilodeau says.
The information is entered into Pfizer Health Solutions’ Clinical Management System software, which tracks and analyzes the outcomes.
During the first visit, the nurse and pharmacist spend 45 minutes or more talking with the patients about their conditions, the medications they are taking, diet, exercise, nutrition, and answering questions and concerns.
"Most patients have a lot of questions that they can’t get answered in a 15-minute office visit," Cleary says.
On subsequent visits, patients go through an intensive educational program that typically lasts two to three months.
"There is a significant enhancement on the educational side, and we feel like we are moving the patients toward a joint compact of compliance, buy-in, and understanding," Cleary says.
Many patients with chronic diseases are not compliant. They don’t follow their diet and don’t exercise.
"This type of approach gets them owning what needs to be done and improving their health and lifestyles. And by having a better lifestyle, they are less likely to be hospitalized as often," Cleary says.
The aim of the Center for Wellness Education is for the staff to spend as much time as necessary with the patients. For instance, if a diabetes patient has elevated blood sugar and needs to get it under control, he or she may come in several times in a week.
"The staff can spend a lot more time educating. A physician may not have 90 minutes to spend with a patient," Cleary says.