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Hospital and HMO case managers in the University of Alabama in Birmingham Health System have joined together for a congestive heart failure (CHF) quality improvement project.
"All case managers are working together to monitor care across the continuum," says Karen Knight, RN, CCM, CDMS, director of health services for VIVA Health.
VIVA is owned by the University of Alabama in Birmingham (UAB). About 75% of its patients go to the UAB health system.
CHF was chosen because it is one of the most frequent diagnoses for admission and readmission with VIVA’s Medicare population.
The UAB case management department administration and VIVA’s administration meet monthly to identify problems and trends.
"One of the things we noticed is that congestive heart failure has the highest admission and readmission rate," Knight says.
Knight is hopeful that the project will help case managers in various setting across the continuum learn to work together for better patient care.
"In the last few years, everybody wanted to be a case manager. You have case managers in home health, in the hospital, in managed care companies. At times, it’s almost been adversarial, but if we’re going to reach the next level of outcomes and better benefit our patients, we’ve got to learn to work together," she says.
The project is part of VIVA’s initiatives to meet HCFA guidelines for Medicare Plus organizations. HCFA requires the organizations to implement two quality improvement studies per year over a three-year period. This is the first year of this project for VIVA and the UAB Health System.
VIVA has purchased kits with materials that CHF patients need to monitor and manage their disease. The kits, called Careguides, are produced by Chicago-based Care Products and include a scale, a blood pressure cuff, a journal, a medication organizer, and educational materials that include step-by-step instructions on what patients should do as well as information on the disease.
"Education is an important way case managers can empower people to take care of themselves," Knight says.
The University Hospital case managers deliver the kits when the patient is in the hospital and start the patient education program. Once the patients go home, the VIVA Health case managers follow up with phone calls and home visits.
"You can have a great impact on CHF with patient compliance. So many times when patients don’t follow instructions, it’s because they didn’t understand. Especially with the elderly, it has to be a repetitive process. You think they’ve got it, and then call back three days later, and they have no idea what you’re talking about," Knight says.
Confusion and failure to follow instructions are particularly prevalent when patients are newly diagnosed, she adds.
The patients in the program require frequent monitoring. The case managers call them at least once a week, asking about weight gain, diet, and other symptoms.
"As they identify the needs, they can act on those needs," she says.
The case managers do far more than just talk to the patients about their weight and blood pressure.
"My case managers recognize that patients have needs outside the disease itself and act upon that," she says.
For example, one patient set up his medicine regime and the plan did not cover the expense of sending a nurse out. The case manager found that the man’s pastor visited him once a week. She got the home health nurse to visit with the pastor and teach him how to set up the patient’s medicine.
"We have reached a time that the needs of patients, especially Medicare patients, have become so complex that you can’t accomplish a lot unless you are actively involved and have frequent contact with the patients and their families," Knight says.
She cautions her case manager to find out more before labeling patients as noncompliant. For instance, one patient who was receiving home health had missed a doctor’s appointment because he didn’t have transportation. The home health agency wanted to drop him because of noncompliance, but the case manager intervened and arranged for a wheelchair service to pick him up. The patient was very compliant after that.
"It took some digging and research to find out what was going on," she says.
The program started in August after more than two months of planning. The effort is starting out with hospitalized patients. "Due to staff resources — we’re small — we had to start small," Knight says.
The health plan is looking at alternative ways to enroll CHF patients who are not hospitalized. "But patients who are frequently hospitalized fit in nicely with this program," she says.
(Editor’s note: Careguides are a series of disease management and other health care product kits available from Chicago-based Care Products. The kits include materials and step-by-step instructions for post-surgical care and disease management in the home.
For more information, contact Care Products at (847) 855-8777 or visit their web site at www.carekit.com.)