Comorbidity and DM.
More than 5 million Americans have congestive heart failure (CHF), and close to 20 percent of that population was admitted to the hospital in 1997. An estimated $18 billion to $20 billion is spent annually on CHF care.
In addition, approximately 10.3 million people have been diagnosed with diabetes mellitus. Diabetes costs the U.S. at least $98 billion in 1997 for supplies, hospitalizations, lost work, disability payments and premature deaths, according to the American Diabetes Association (ADA). Because of their prevalence and expense, and because their prognosis can be strongly affected by patient behavior, these chronic conditions are among the top candidates for disease management (DM) programs.
Challenge for DM
Chronically ill patients often have more than one condition. According to the "Healthcare Cost and Utilization Project Fact Book #1," more than half of all hospitalized patients have at least one comorbidity, with one-third of patients having two or more conditions. Hypertension, lung disease and diabetes are the most common comorbid conditions. McKesson Corporation, a provider of DM services, reports that 28 percent of CHF patients participating in its CareEnhance[SM] Disease Management program also have diabetes, and 62 percent of diabetics have hypertension.
These multiple conditions create complex issues for disease management which current applications are beginning to address. DM systems can help coordinate resources, education, monitoring and counseling for patients with more than one condition. But it also takes sophisticated nursing skills to coordinate a personalized disease management program that manages a patient's total health, reducing hospital stays and costs while improving clinical outcomes and quality of life.
Technology provides the framework to deliver individualized interventions based on the patient's health status. Drawing on a combination of evidence-based clinical guidelines defined by organizations such as the ADA, American College of Cardiology, the American Heart Association, and the Agency for Healthcare Research and Quality, a DM system puts the best clinical information at the nurse's fingertips every time he or she counsels a patient. The application guides the nurse to ask appropriate assessment questions, and the system provides information based on patients' responses.
DM nurses provide coaching to make sure multidisease patients make appropriate behavior changes. In the case of a patient with CHF and diabetes, a nurse will teach the patient to commence daily weight monitoring, monitor his glucose, take his ACE inhibitors and make behavioral changes to improve his health and functioning. While the application prompts the questions and flags danger signs, the nurse provides the contact and professional judgment.
Communication Is Key
The DM system also facilitates communication among all the members of the health care team, providing a detailed record of the DM nurse's encounters with the patient, making it easy to send messages to the patient's doctor as necessary. Nurses can send clinical alerts when they detect a problem or treatment program compliance issue, or if the patient experiences symptoms during the phone call. An alert message is faxed to the patient's doctor apprising him or her of the situation. Because the condition guidelines, patient data and program outcomes are shared among all the patient's caregivers, the care given is coordinated and consistent, providing a strong decision support platform for provider, case manager and patient alike.
Take the case of a one 59-year-old patient with both CHF and diabetes. Feeling there was nothing she could do about her condition, she didn't bother to test her glucose. She was so severely overweight that she couldn't use an ordinary household bathroom scale, so she wasn't monitoring her weight, let alone trying to control it.
Through three months of counseling calls, Brian Michaels, an R.N. in McKesson's DM program, persuaded her to make an appointment with a nutritionist, a referral he facilitated through a message to her doctor. He also discovered that she wasn't testing her blood sugar because she couldn't afford the testing supplies and made the appropriate contacts to get her that equipment. While his actions were based on clinical guidelines and prompted by the workflow system, the success is the result of the human touch.
Care providers in our program have seen a 33 percent increase in glucose monitoring among diabetic participants, a 28 percent reduction in missed workdays and a 33 percent reduction in hospitalizations. For participants with CHF, the program has reduced readmissions for cardiac-related symptoms by 30.4 percent and has shown a 73 percent reduction in inpatient readmission rates.
Human Touch Helps
In some cases, it's a matter of making sure a patient gets the right care before a situation gets too serious. One routine monitoring call to a 73 year old, also with CHF and diabetes, was answered by the patient's daughter, who said her mother wasn't feeling well, but had decided to wait through the weekend to see if she felt better before seeking medical attention.
The DM nurse reviewed the patient's symptoms and sent an automatic alert fax to the patient's doctor, who then called the patient and insisted she go in to be evaluated at once. Supported by the application, the nurse was able to make a quick judgment and get a message to the doctor that probably saved this patient's life.
As systems for disease management grow more sophisticated, the support they provide in the management of complex patients will improve. But even now, they are putting the best treatment information at the fingertips of disease management nurses, and giving them the technological tools to simplify the management of complex cases, helping to reduce healthcare utilization and costs. Technology provides the right information at the right time; nurses provide the heart.
Margaret Flaum, R.N., is director of population care client management at McKesson Health Solutions in Broomfield, Colo.