Innovative Approaches to High-Risk Patient Management
Three Medical Groups Honored for Diverse Projects
Group Practice Journal

Advancements in medicine and technology have paved the way for medical professionals to develop innovative approaches to care. In an effort to recognize and reward medical groups with outstanding programs to improve clinical outcomes for high-risk patients, the American Medical Group Association®(AMGA) collaborated with Pfizer Inc. to create the Models of Excellence in High-Risk Patient Management Award.

This annual award was first presented in 2000. This year, three organizations were recognized, all with implemented projects: first place ($50,000) was awarded to Midwest Heart Specialists for its Virtual Lipid Clinic; second place ($30,000) went to Franciscan Health System for its Improving Care Through the End of Life program; and third place ($20,000) went to St. Mary's / Duluth Clinic Health System (SMDC) for the Heart Failure Disease Management Program.

The Heart Failure Disease Management Program
St. Mary's / Duluth Clinic Health System

In 1998, the St. Mary's / Duluth Clinic Health System (SMDC) in Duluth, Minnesota, a large primary and multispecialty clinic and hospital system, identified specific goals to help the 9,000 patients with CHF in its care. Using an office-based protocol, the SMDC Heart Failure Disease Management Program evaluates and treats heart failure according to national consensus guidelines, provides patient education and counseling, and coordinates care with appropriate referrals to hospice, home care, cardiac rehabilitation, social workers, psychologists, and registered dietitians. It also features a novel approach to monitoring a patient's condition between office visits: a talking weight scale placed in patients' homes.

A patient responds to questions asked by a talking scale–part of the comprehensive program for heart failure patients at
St. Mary's / Duluth Clinic Health System.

Located in the cardiology department, the program strives to:

• Improve medical treatment in accordance with national consensus guidelines

• Improve patient quality of life and functional capacity

• Reduce unnecessary utilization of inpatient care and overall care costs

At the core of the SMDC Heart Failure Disease Management Program is regular contact between the medical group and its patients. During the early development stages for the program in 1997, the organization realized, "disease management involved specialty care for the office visits," says Cardiology Nurse Practitioner Kristin Ryan. "But without some sort of surveillance between office visits in terms of disease progression, we were not going to be able to achieve the desired impact on quality and costs." The medical group originally provided case management through weekly one-on-one telephone calls. When the population rose to 100, this practice became staff-time intensive, and the lack of objective data decreased the value of this intervention.

SMDC then began evaluating telemonitoring programs from various vendors across the country, but none seemed adequate for the needs of the program. At that time, a Minnesota vendor was looking for a site to pilot its new cardiac telemonitoring scale, and SMDC was willing to test the technology. "It was the first vendor to offer an interactive feature asking the patients about symptoms," Ryan notes. "The scale displays digital questions based on typical symptoms associated with heart failure, with 20 questions interchangeably used on different days. In addition, the medical group can add customized questions if desired. Questions are available in several different languages and appear in the box at the top of the scale. There's a woman's voice that asks the questions, which is good for our patients who are legally blind, and the 'Yes' and 'No' buttons have Braille on them."

The scale quickly transmits daily weight and symptom data to SMDC. If there's a problem, a nurse practitioner knows at once, calls the patient for more details about what was reported, and performs a nursing assessment. Then a report is generated and reviewed by Ryan, who works in collaboration with the program's director, Dr. Carl Heltne. Appropriate adjustments–usually to the patient's oral diuretics–can then be made by phone. So far, over 90 percent of patients in the telemonitoring program have expressed high satisfaction.

Medical group treatment goals exceed national benchmarks with 98 percent of participants now on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, and 83 percent currently on a beta blocker. The preprogram levels were 66 percent and 78 percent in two studies for ACE inhibitors and 59 percent for beta blockers. Hospitalizations were reduced by 82 percent and ER visits by 88 percent during an initial pilot with the telemonitoring system. Patients have also shown the following improvement in functional status and quality of life:

• Quality of life improvement (Minnesota Living With Heart Failure Questionnaire score)
   shown by 50 percent of patients

• Function status improvement (New York Heart Association class) indicated by
   73 percent of participants

• Functional status improvement (six-minute hall walk test) seen in 52 percent of patients

• Ventricular function improvement (left ventricular ejection fraction measurement)
  shown by 63 percent of patients

These numbers indicate that this innovative and comprehensive heart failure disease management program has produced impressive results. The next generation of treatment programs can use this model to bring many different one-on-one and technological elements together for better patient outcomes.

Benjamin Eng, M.D., M.A., is medical director/group leader of the Customer Outcomes Group at Pfizer Pharmaceuticals Group, Pfizer Inc.

Julie Sanderson-Austin, R.N., is vice president, quality and operations improvement at the American Medical Group Association, headquartered in Alexandria, Virginia.