Chronic care success requires innovation

Agencies provide special training for clinicians

While the Centers for Medicare & Medicaid Services (CMS) introduces new programs designed to address the care of chronically ill patients, home health agencies continue to find innovative ways to provide care to diabetic and congestive heart failure (CHF) patients — two of the most common diagnoses identified as chronic illnesses.

"We provide care to 4,000 patients, and half of them are considered chronically ill," says Ray Darcey, vice president of Sentara Home Care in Chesapeake, VA. "The most common diagnoses are diabetes, CHF, and chronic obstructive pulmonary disease [COPD]," he says.

After identifying CHF patients as the group for which costs were increasing and reimbursements were decreasing, Darcey’s agency evaluated different ways to continue providing quality care at a lower cost. "We do have standard protocols that we follow for all of our chronically ill patients, and those do streamline our care. But we wanted to see if telemedicine would help us reduce our labor costs," he notes.

The telemedicine program for CHF patients was introduced four years ago. "The program involves a combination of telemedicine and nursing visits," Darcey explains. "The telemedicine visits are designed to supplement — not completely replace — nursing visits. Our program is a live, interactive video that requires a computer screen and a telephone line. The patient’s unit has a blood pressure cuff, a scale, and a stethoscope that are used during the telemedicine visit, with the results appearing on the nurse’s screen."

Although the program has reduced staff costs because nursing visits to the home can be reduced, it also has produced some other significant results, he says. "We’ve seen a 70% reduction in hospital readmissions, a 78% decrease in emergency department visits, and a 50% improvement in activities of daily living for our CHF patients on the telemedicine service," Darcey notes.

The 60 patients on Sentara’s telemedicine program are between 65 and 80, and none of them were apprehensive about the use of the telemedicine equipment, he says. "There was no hesitation, and we’ve discovered an unexpected bonus to the telemedicine program," Darcey says. While the patients are not nervous about the equipment’s digital camera sending their image to the telemedicine nurse, they are especially careful about their appearance during the telemedicine visits, he points out.

"When nurses go to the home to see these patients, many of them will still be wearing their pajamas. But for the telemedicine visit, the patients dress up, put on makeup, and fix their hair," Darcey laughs. Their attitude also is different, he adds. "They take their responsibility for their care between visits very seriously, and they are diligent about recording the information the nurse will request during the telemedicine visit."

The telemedicine patients see this program as a way for them to participate in their care, and their attitude and approach to self-care has improved greatly, he adds.

Patient satisfaction scores have increased

Although Sentara did experiment with the use of the same nurse for both the telemedicine and in-home visits, Darcey notes it was not an efficient use of staff time. "Some of our patients live over 100 miles from the office with the telemedicine equipment." Scheduling the nurses who cover these distant areas to come to the office to make telemedicine visits wasn’t effective, he explains. "Patients don’t mind two different nurses overseeing their care, and patient satisfaction scores for this group of patients has increased."

In addition to having their own CHF program that includes comprehensive protocols and patient education, Sta-Home Health Agency in Jackson, MS, has targeted diabetic patients as one group to receive special attention to reduce complications and the need for hospitalization.

"We have a team approach to caring for diabetic patients that includes nurses, diabetes educators, and dietitians to make sure our patients receive the best education and care," explains Michael T. Caracci, chief executive officer. "All of our nurses are familiar with the potential complications and the neuropathy of diabetes, and we have seven certified diabetic educators on staff to serve as resources for the nurses and to visit patients," he says.

Agency offers foot-care clinics

In addition to comprehensive patient education for his agency’s own home care patients, Caracci’s staff offer foot-care clinics through physician offices. The clinics are held in the physician’s office for patients of that practice. "One of our nurses, along with the physician, will talk to the group of patients about foot care in general for diabetics. Then our staff will work with each patient on an individual basis to trim toenails and check feet," Caracci explains.

To avoid any Stark violations, the physician pays the agency on an hourly basis to provide the education and the foot care, he adds.

Because Caracci’s agency covers a wide geographic area with 40 offices and more than 4,000 patients, it is not possible for diabetic educators to see every diabetic patient on a regular basis. That doesn’t mean that nurses don’t have access to the diabetes educators as a resource, he points out. "Although our nurses are well-trained in the care of diabetic patients, there are times when they may need advice," Caracci says.

Nurses can reach the diabetic educators by phone or e-mail. Also, if nurses are concerned about a patient’s skin breakdown, they can use digital cameras to give accurate information about the patient’s skin condition. "We don’t use telemedicine at this time, but we do have digital cameras in each of our offices that nurses can use to photograph a patient’s wound and transmit the picture to the diabetic educator," Caracci says. "This makes it possible for the educators to determine if the patient should be seen by another clinician or themselves for other treatment."

While technology such as digital cameras is affordable for most agencies, Darcey admits that telemedicine requires a significant investment. "The cost of training nurses to use and set up the equipment in the patient’s home is not much, but the equipment and software can add up," he admits. "We are fortunate that we are part of a larger health system with several hospitals. The reduction in readmissions and emergency department visits and a shorter length of stay when hospitalization is needed for CHF patients combined to make a strong argument in favor of the investment in telemedicine," he adds. "We are planning to expand our telemedicine program to include COPD this year, and we expect to see positive results for those patients as well," he says.

As CMS proceeds with chronic care improvement organizations and demonstration projects, some agencies such as Sta-Home will work with the chronic care organizations to provide the face-to-face visits required for some patients. "I think it is important to make sure that technology and emphasis on efficient care and education don’t completely replace actual visits," says Caracci. "There are things you learn about the patient when you are in the patient’s environment that won’t always be communicated because the patient doesn’t consider them pertinent," he explains.

Daylong visit reveals blood-sugar culprit

Caracci’s favorite example of the importance of being in the home is his agency’s experience with a diabetic patient whose blood sugar levels could not be controlled. Repeated visits to the patient and reinforcement of education were not working, so a nurse spent the entire day at the home to see if she could determine what the patient was doing, or not doing, to prevent control of her blood sugar level without sending her back to the hospital, he continues. "Everything was fine from 8 a.m. until 3 p.m., with the patient eating correctly, checking her blood sugar, and doing nothing that explained her out-of-control blood sugar. At 3 p.m., the woman’s granddaughter stopped at the house on her way home from school carrying the special treat she brought her grandmother every day — a Slush Puppie," Caracci says.

The nurse looked at the sweet frozen drink and knew why the woman’s blood sugar levels couldn’t be stabilized. "The woman and her granddaughter never mentioned the daily treat because it never occurred to them that this one drink could cause so many problems," he adds. "The nurse suggested other treats that the granddaughter could bring that wouldn’t make hospitalization necessary."