Heart failure program proves that DM works — even under fee for service
Disease Management Advisor

While DM has long been considered a crea-ture of managed care, an increasing number of organizations are experimenting with the concept under fee for service medicine. The most note-worthy of these is Medicare's large coordinated-care demonstration project, which is tracking the financial and clinical outcomes resulting from several different DM and/or case management approaches.

Additionally, health systems looking to pare down costs from unprofitable admissions are investigating ways to lower the hospital and ER utilization rates of patients with these high-cost/ low return diagnoses. That was one of the motivating factors driving development of a heart failure program at St. Mary's/Duluth Clinic Health System (SMDC), a large integrated system in Duluth, MN, that includes 24 primary care clin-ics and three acute care hospitals. Operating in a fee for service setting, SMDC didn't have the funds to outsource management of heart failure (HF) to a vendor, so over the course of four or five years, administrators researched what other organizations were doing successfully with regards to HF -- an effort that led to development of an in-house program that has been able to boost quality of life and stan-dards of care while turning a money-losing diag-nosis into a profitable one.

Comprehensive approach needed

Recognizing the huge burden involved with caring for HF patients, a cardiology group at SMDC first began considering the need for new approaches to treatment several years ago. "The frequency of hospital admissions, the poor quality of life, and the dire prognosis for these patients were all triggers for the cardiologists to ask what they could be doing differently," explains Kristin Ryan, MA, RN, CNP, who is now the heart failure program manager at SMDC.

Following a comprehensive review of the lit-erature on HF, and visits to other cardiology pro-grams that were implementing DM programs of their own, SMDC cardiologists decided they needed a program that combined additional spe-cialty medical management with greater nursing surveillance, and a system of providing some for-mal education about HF to patients. With these considerations in mind, Ryan developed a plan of care for HF patients that focused on the need of most patients to have their medicines titrated appropriately, to obtain prompt and appropriate referrals for additional resources, and to learn the basics regarding lifestyle management of HF.

Program begins with intensive, up-front care

To accomplish these primary goals, Ryan and colleagues developed a four-visit clinic protocol for every HF patient. The protocol begins with a comprehensive cardiology consultation that includes nurse practitioner involvement so that providers can fully review the patient's medical history, ascertain what diagnostics have been done, and what additional testing might still be needed in order to construct an optimal program of care.

"Usually I begin with the initial part of the history taking, and I will do my own review of the patient's medical history by way of a thor-ough chart review as well as a review with the patient," notes Ryan. She also covers social his-tory and family history, and reviews all of the patient's medications with him. At this point, the cardiologist speaks with the patient, going over some of the same general areas as Ryan, but also completing a physical exam. Once all the appropriate information has been collected, the nurse practitioner works with the cardiologist to design a care plan for the patient, and then they discuss this plan with the patient jointly. While Ryan plays a significant role in this initial consultation, the visit is billed by the cardiologist.

The second, third, and fourth clinic visits generally take place over the next two months, and they are designed to further the medical goals established during the initial comprehen-sive visit. "Frequently we will adjust ACE inhibitors, the initial beta blocker therapy, and diuretic therapy, and do the lab monitoring that goes along with that," says Ryan. "Then we break out our formal educational package into a one-on- one education session with the patient using a registered nurse here in our office. At each of his visits, the patient will receive a component of that education."

Phone calls inefficient

Early on, when Ryan was the only staff mem-ber of the program, she was responsible for most of the office visits as well as follow-up phone calls made once a week to each patient to check on weight and HF symptoms. Within six to ten months of beginning the program, Ryan realized she was not going to have the time to handle all the phone calls indicated in the program's proto-col, and she felt as though the phone call approach was not efficient or productive in many instances. "What I was sensing with patients was that they loved the attention, and that the satisfaction with the calls was pretty high, but effectiveness was low, whether you caught them on a day when they were doing well and you really ended up with a social chat, or you didn't know if what they were telling you about their weight was true because there was no objective data to go by," explains Ryan. She also points out that, under fee for service, all of the time that went into these phone calls was not reimbursed. In an effort to improve the process, Ryan and colleagues at SMDC began to consider alternative approaches to the monitoring component of the program. They considered outsourcing HF man-agement to a third-party vendor, but found that at $150 to $200 PMPM, the expense was too high to cover without reimbursement. Further, they were hesitant to bring yet another entity into the patient care picture. "These patients are already seen in primary care, and they may also be seen in the VA system to get their medicines. Further, they have multi-speciality physicians involved, and we felt like [adding another party] would actually worsen care coordination rather than better it," recalls Ryan.

SMDC considers in-house program

Consequently, SMDC administrators began to focus in on the idea of operating their own telemonitoring equipment. To that end, SMDC began talking with officials at Cardiocom, a young Minneapolis, MN-based company that specializes in interactive DM products and ser-vices for daily home monitoring. While Cardio-com offers a full HF DM program -- including equipment and patient monitoring -- to those interested, it will also lease its equipment to clients who prefer to staff their own manage-ment/ monitoring programs. In fact, a growing number of clients are interested in the latter type of arrangement, according to Dan Cosentino, president of Cardiocom. "More and more health plans are finding that with the right products, they can do this them-selves. Instead of sharing the savings or paying an outsourced vendor management fees, they can apply their own case management resources and use our products, and it works out to be a very low monthly PMPM with a pretty substantial savings," explains Cosentino, noting that an aver-age ROI through this approach is 5 to 1. "We have had large health plans use an outside DM vendor and then decide that it was more cost-effective to do this themselves and switch to our in-house program."

Interactive scale collects information

The system Cardiocom offers for HF includes a specialized weight scale that is accurate to a tenth of a pound. "It has a pedestal that comes up to waist height, and on that is a small box that has an LCD screen and a 'yes' and 'no' button," explains Ryan, noting that the Telescale, as it is called, is also equipped with a voice module. When patients get up in the morning, they are asked to weigh themselves and use the "yes" and "no" buttons to answer a series of symptom and compliance-related questions that Ryan has selected for them. "There are ten standard ques-tions, but there are also additional questions that we can turn on or off for the patient," notes Ryan. Typical questions that the Telescale is pro-grammed to ask patients include the following:

     • Are you more short of breath?
     • Are your ankles or feet swollen?
     • Do you have any abdominal bloating?
     • Are you experiencing any chest pain?
     • Did you remember to exercise yesterday?
     • Did you take all of your medicines?
     • Are you trying to reduce your sodium intake?

Once this daily "health check" is completed, the Telescale dials up a toll-free phone number and transmits the information via telephone lines directly into a server located at SMDC. Triage software provided by Cardiocom has the ability to recognize each patient's information and orga-nize it so that a nurse can quickly tell which patients have been identified as having "weight" or "symptom" alerts that should be fol-lowed up on with a phone call. The software has the ability to trig-ger alerts because specific "weight" and "symptom" parameters have been estab-lished and programmed into the soft-ware for each patient. When a patient's weight is beyond those parameters, the nurse monitoring the software program will be alerted to call the patient, ascer-tain his condition, and advise him to adjust his medications or, if needed, come in to see his physician. "The most typical thing we see with HF is that a patient's weight fluctuates, and we try to catch this within 3 lbs to 4 lbs of their dry weight so that it doesn't provide additional cardiac strain that could get out of hand and lead to an ER visit or a hospital stay," notes Ryan.

'Management by exception' approach

Essentially, the system allows clients to identify and call back only those patients who need assistance as opposed to every patient. "It is what we call a management by exception process," stresses Cosentino. "Generally our clients see about a 10% to 15% daily exception rate, and that means if a nurse is monitoring 200 patients, she would call back approximately 20, and when she called back she would know specifi-cally what their weight was, their symp-toms, and what she has done in terms of treating them in past." Further, through an "Exception Report" produced by the software pro-gram, the nurse can communicate to the managing physician a full 21 days worth of symptoms, weights, and medications, as well as any comments that the nurse has made. "It is over time, but it is giv-ing the physician a snapshot of why the patient is out of bounds," notes Cosentino. (See Figure 1.)

Clinical, financial gains

The Telescale system has proven to be a huge asset to the SMDC program, according to Ryan. She notes that continuous monitoring of quality of life, functional capacity, and quality indicators such as the number of patients on ACE inhibitors, beta blockers, and other medicines have all reflected steady improvements. Further, the system has had a positive financial impact. "Even in a fee for service environment, we are integrated so if we are losing money on the hospital side, we need to make it up by keeping patients out of the hospital and treating them in a clinic setting, and indeed we have," explains Ryan. "We saw an average of $750 per patient in cost shifting. In other words, we were losing about $500 per patient in the six months before they came into the program, on average, and in the six months after they entered the program we were profiting about $250 per patient." Other outcomes reported for the Telescale system include the results of a one-year study which looked at the hospitalization rate for about 1,000 HF patients. 1 The study, which took place from August 2000 through July of 2001, enrolled patients from nine independent sites, including three managed care facilities representing 64% of the participants, and six hospital groups, repre-senting the remaining 36% of the participants. While Cardiocom completed the study, and the participating organizations were the compa-ny's own clients, the company did not have any involvement in patient selection. Rather, patient enrollment and selection was determined solely by the staff at each facility based largely on which patients could most benefit from the sys-tem. The mean HF admission rate for study par-ticipants was .234 admissions per patient per year across the nine facilities. This compares very favorably with the reported unmanaged inci-dence of about 2 HF admissions per patient per year, according to study authors. (See Figure 2.) Further, the average LOS for the study par-ticipants who were hospitalized was 6.4 days. Study authors note that this figure compares favorably with reported national statistics, which peg average LOS for HF in the 7 to 9.1 days range. (See Figure 3.) Study authors emphasize that in all cases, participating facilities were able to eliminate intensive outbound calling to HF patients in favor of the Cardiocom management-by-excep-tion process where only those patients with symptom or weight triggers required phone-call follow-up.

Challenges remain

With the success of the HF program at SMDC, certain components have evolved and changed over time. For example, initially most of the participating patients were referred into the program by the cardiologists who work closely with Ryan at SMDC. "They felt like they put the work into helping to design the program, and my salary was from the department, so I initially started taking over the very challenging and dif-ficult- to-manage patients in our own depart-ment," explains Ryan. Gradually, however, the program began to accept referrals from SMDC's acute care hospital in Duluth, and now the pro-gram is receiving a growing number of referrals from PCPs who will call Ryan's office to ask that one of their HF patients be enrolled.

Along with expansion of the program, how-ever, there are new challenges. For instance, all 125 of the Telescales that SMDC has budgeted for are now in use, meaning that only about one-third of all the HF patients in the program have a Telescale. This means that program administra-tors must carefully select which patients would most benefit from a Telescale.

"We feel like the patients with the scales are getting A-plus service from us," notes Ryan. And while the rest of the patients receive the four vis-its called for in the HF protocol, and regular fol-low- up visits based on their status, Ryan is cur-rently investigating how she can most effectively monitor these patients. "In between visits . . . we need to figure out how to get that phone call out to patients, whether it be every week or every two or three weeks. We need to extend ourselves out and not just wait for problem calls."

Franchising on the horizon?

While administrators work on that issue, they are also looking into the possibility of offer-ing their HF program to other organizations. In fact, the program is already working with Blue Cross and Blue Shield (BCBS) of Minnesota on a limited basis, and receiving reimbursement for the telemonitoring services. The arrangement began as a pilot study, but satisfaction with the program, on the part of patients as well as providers, is such that the arrangement keeps being extended. Initially, the program appealed to BCBS, at least in part, because it was local. "We knew the providers. It was more than just a vendor program. It wouldn't be someone from South Carolina call-ing the doctor and saying that his patient is show-ing up bad on the computer according to his scale readings. We felt like they had some advantages," explains Douglas Hiza, MD, medical director for provider relations at BCBS Minnesota. "They capi-talize on their relationships with providers in the region to have more personal contact with the physician. They are working with the physician in a very personal way to monitor and take care of patients. That is what makes it really unique as opposed to a vendor's relationship."

Hospitals a good fit for HF approach

While SMDC was one of Cardiocom's first clients, it is now one of many. And the circum-stances that brought SMDC to Cardiocom are hardly unique, according to Cosentino, who notes that hospitals now comprise about half of the com-pany's customer base. "Hospitals, we think, are turning to the Cardiocom system because many of them are short in terms of nursing staff, and they are also at or over capacity in terms of available beds. And HF represents one of the lower DRGs when you look at cardiac DRG payments," he explains. "And if you consider LOS, the hospitals are looking at their economics and concluding that their beds are full. [They want to know] how they can manage some of these patients in an outpatient setting and free up their beds for potentially higher DRG opportunities." Every client on Cardiocom's system has increased its use of the Telescale home monitor-ing device, notes Cosentino, emphasizing that the monthly rental fee for a Telescale gets more rea-sonable with increasing numbers. "The cost per patient per month with a standard of 100 patients is $85," he explains, adding that the company will consider risk-sharing and other arrange-ments. Additionally, the rental fee includes the software package, which can be used to manage patients with other disease states as well. Stresses Cosentino, "It is really a comprehensive clinical management system." Pleased with the results from the Telescale device, Cardiocom has recently introduced a sec-ond device to help one of its existing clients better monitor COPD patients in much the same way as the Telescale assists with HF patients. While the new device will first be used with COPD, it has other capabilities as well. "It is a multi-disease state management device that is very similar to Telescale, but it does not include the weight com-ponent," says Cosentino. "It also has the ability to [help monitor] asthma patients and diabetes patients. All of that was designed into the device." Editor's note: For more information about Car-diocom, access the organization's website at www.cardiocom.net.

Reference

1.Kramper E, Cosentino D. Multi-Center Study of Hos-pitalization for Heart Failure Using a Home Monitoring Sys-tem in Managed Care and Hospital Facilities. Cardiocom, LLC 2001.