Customized Clinical Case Management for Chronically Ill Patients.

Health system sees remarkable results with teams of case managers, physicians, patients

Securing excellent care and positive outcomes for seriously ill, high-risk patients requires extraordinary measures. A health system in Georgia is experiencing strong results by taking a team approach to health care with case managers, physicians and patients working together.

WITH LIMITED RESOURCES and declining reimbursement for services, the health care industry continues to search for new ways to improve efficiency and effectiveness.

The past few years brought waves of consolidations, mergers, systems integration and niche market development; all seeking to stabilize or enhance bottom line performance while preserving or improving clinical quality and patient/payer satisfaction.

From a medical management perspective, performance profiling, repetitive engineering through clinical guidelines, and traditional utilization management strive to generate improvement by minimizing undesirable variation.

Though all these measures have real or potential merit, they do not adequately address one essential aspect of medicine: the need to customize care for high-risk individuals with inherent variation and who often require large amounts of health care resources.

Aggressive multidisciplinary inpatient management of these populations meets with some success, but ambulatory interventions over time appear to be an opportunity for further improvement.

The WellStar way

WellStar Health System, a community-based integrated delivery system in Atlanta, Ga., is tackling this issue with outpatient nurse-based clinical case managers.

And with careful planning, the large health system with five hospitals and a 600-member multispecialty physician group serving five counties and nearly one million people is seeing signs of success.

Early in its development, WellStar chartered the care management committee, a multidisciplinary group consisting of physicians, nurses, representatives from ancillary services and senior executives.

This group is charged with creating clinical design initiatives, essentially functioning as a think tank for the medical management division of the system. It prioritizes opportunities based on:

* Potential clinical impact

* Operational efficiencies

* Patient service

* Regulatory requirements

As one of its first initiatives, the committee sponsored a task force to evaluate the systems' approach to congestive heart failure (CHF). It looked at physician office activities, referral patterns, hospital resource utilization, tools already in use and disposition planning.

With those baseline data sets and extensive literature searches, best practice opportunities were identified. This led to inpatient and outpatient clinical guidelines, standardization of inpatient orders and development of education materials for both patients and physicians.

During this process it became clear that WellStar needed to find a better way to manage its most severely ill patients whose complex clinical courses generate large resource requirements.

The group believed a program of clinically oriented ambulatory nurse case management would be of value in these high-risk patients and endeavored to develop a program to address these unmet needs. [1] The goals were to:

* Enhance the patients' quality of life.

* Improve the quality of care delivered by the system while decreasing associated costs.

* Provide comprehensive education for disease processes while promoting self-management.

* Give emotional support to patients and their families.

* Enhance collaboration between patients, families and providers of care.

The hallmark of WellStar's program is contact between patients and case managers that may occur in the home, the physician's office or by telephone. The frequency and method of contact is up to the case managers and tailored to meet the needs of each patient.

The program is designed to evaluate the effectiveness of each patient's treatment plan in real time with the expectation that people with severe chronic illness require frequent and, at times, unexpected alterations in therapy. Changes in status are discussed between the case managers and the patient's physicians.

To function well in such a relatively unstructured and empowered environment, case managers are carefully selected and trained. Each candidate's clinical experience and expertise is evaluated and WellStar looks specifically for extraordinary interpersonal skills.

Training includes an intensive education program that focuses on evaluation and therapy for CHF and the goals of the case management program.

Patients are screened prior to their entry into the program to ensure that they require this degree of customized management. Criteria for admission include:

* High levels of historical resource utilization.

* Complex pathophysiology.

* Lack of understanding of their disease processes.

* Psychosocial or financial issues that place them at high risk for poor outcomes.

Once admitted, patients are continuously reassessed to see if they require ongoing services and are discharged from the program if they are no longer needed. Using these approaches, case managers generally maintain a census of 75 to 90 patients.

Program reaps results

WellStar evaluates each of its medical management initiatives by resource utilization, clinical outcomes and patient satisfaction.

Resource utilization measurements for this project include rates for hospitalization and emergency department visits. Each patient's data are calculated before and after enrolling in the program.

If a patient has been in the program for six months, his utilization rate is measured for the six months prior to entry and the six months following enrollment. With a patient experience of more than 240 individuals, hospitalizations decreased 78 percent, and emergency department visits decreased by 76 percent. These measurements have remained remarkably consistent over the life of the program.

To evaluate clinical outcomes, WellStar uses the Minnesota Living with Heart Failure tool to assess both the physical and the emotional well-being of patients participating in the GHF program. [2,3] This instrument assigns a numerical score to a series of questions related to each of the two areas.

WellStar administers the questionnaire at the time of entry, quarterly for the subsequent year and annually thereafter. Figure 2 shows the results of these metrics to date and indicates significant improvement in both parameters.

It's believed that the early improvement in physical outcomes is related to consistent medical therapy and early detection of signs of clinical deterioration. The progressive, sustained improvement in emotional well-being may be a byproduct of the evolving relationship between patients, case managers and physicians.

WellStar also follows the percentage of patients receiving angiotensin converting enzyme inhibitor (ACEI) therapy (76 percent) or appropriate alternatives if intolerant to ACEI therapy (13 percent).

These figures compare favorably with previously published experiences. [4-8] Whether these results are related to case management or clinical guidelines and education of providers is unclear, although WellStar frequently hears reports of case managers reminding physicians about opportunities to alter medical therapy.

Patient satisfaction is assessed by an internal confidential questionnaire that addresses four topics:

1. The case manager was helpful and seemed concerned with my well-being.

2. As a result of being in the program, I have been able to better understand and manage my heart failure.

3. This type of program would be helpful to other patients with health problems.

4. I was able to avoid going to the emergency room or being put in the hospital due to the care I received through this program.

Figure 4 shows the percentage of respondents who indicated they strongly agree or agree with each of the four items. Though not statistically validated, these data are supplemented with testimonials from patients in the program. It is clearly one of the best-received programs the system has initiated.

Early warning system established

Case managers see themselves, and are seen by others, as advocates for patients and agents for physicians. The result is collaboration that enhances and strengthens the physician/patient relationship.

Patients see the case managers as an extension of their physician's office and are more apt to be open to high levels of communication. This adds an early warning system for signs of clinical deterioration and allows timely course corrections that prevent more acute illness.

This occurred despite the fact that the case managers implemented no clinical algorithms. WellStar believes the improved outcomes are primarily related to reinforcement of compliance and appropriate early management of clinical exacerbations.

Other significant benefits are an improvement in emotional wellbeing and management of the chronic anxiety and depression that are prevalent in patients with chronic disease. The level of patient trust in the case managers clearly helps with such sensitive issues.

Physician acceptance of this program is very strong. WellStar believes this is because:

* It was developed locally with extensive involvement of providers.

* The case managers are specifically selected for their knowledge, clinical experience and expertise in physician collaboration.

* The outcomes data are convincing in their own right.

Physicians see the case managers as a value-added service to their practice and requests for patient enrollments into the programs now exceeds capacity.

Although WellStar's initial application of clinical case management was for patients with congestive heart failure, the health system subsequently implemented similar programs for pediatric asthma, adult obstructive lung disease, diabetes mellitus and high-risk geriatrics.

Early data show similar results in all these groups, consistent with WellStar's impression that intervention is much more about patients and compliance management rather than disease management.

In a globally capitated risk environment, this type of program is good medicine, good patient service and good business. It effectively contributes to management of expenses.

In a fee for service setting, it is good medicine, good patient service, and bad business. It detracts from potential revenue to providers.

Payer-sponsored programs may avoid this issue since the arbitrage does not reside with providers in fee-for-service payment arrangements. However, the challenge in that scenario is to incorporate the process as a tightly integrated part of the patient/physician relationship, which WellStar feels is essential for success.

Another option is for payers to reimburse such programs developed at the provider level. These are issues that payers and providers need to explore.

Conclusion

The successful management of patients entrusted to a health care delivery system depends on the system responding to changing reimbursement structures with services that emphasize prevention and wellness. At the same time, they must promote independence and active involvement for patients with chronic illnesses.

Clinical case management offers an opportunity to deliver better care to selected high-risk populations with a user-friendly interface and more efficient use of resources. Properly implemented, it makes partners out of physicians, nurses, and patients. .

Larry W. Haldeman, MD, MBA, is the executive vice president of WellStar Health System. He is a graduate of the University of Florida College of Medicine and has been in clinical practice for 21 years.

Tricia Hart, RN, MS,. is the care coordinator manager for the care management division at WellStar Health System. She obtained her nursing degree from Presbyterian Hospital School of Nursing, Charlotte, N.C., a BS in nursing from Kennesaw State University, Kennesaw, Ga., and a MS in nursing from Georgia State University, Atlanta, Ga.

Sharon Read, RN, MN is a clinical nurse specialist in the care management division of medical management for WellStar Health System. She received herBS and MNfrom Emory University Atlanta, Ga.

References

1. cohen, EL, Cesta, T.G. Nursing Case Management. 2nd ed. St Louis, Mosby, 1997.

2. Rector, T.S. "Patients self-assessment of their congestive heart failure. Part 2: content, reliability and validity of a new measure, the Minnesota living with heart failure questionnaire." Heart Failure. 1987 Oct/Nov., 198-209.

3. Rector, T.S. "Assessment of patient outcome with the Minnesota living with heart failure questionnaire: reliability and validity during randomized, double-blind, placebo-controlled trial of pimobendan." Am Heart J 1992, 124:1017.

4. Gattis, W.A., Larsen, R.L., Hasselblad, v., Bart, B.A., O'connor, C.M. "Is optimal angiotensin-converting enzyme inhibitor dosing neglected in elderly patients with heart failure?" Am Heart J. 1998 July, 136 (1):43-8.

5. Cheng, T.O. "Importance of angiotensin-converting enzyme inhibitors in myocardial infarction and congestive heart failure: implications for clinical practice." Cardiology 1996, 87:267.

6. The Large State Peer Review Organization consortium. "Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 states." Arch Intern Med. 1997, 157:11031108.

7. Stafford, R.S., Saglam, D., Blumenthal, D. "National patterns of angiotensin-converting enzyme inhibitor use in congestive failure." Arch intern Med. 1997, 2460-2464.

8. Rich, M.W., Luther, P. "Temporal trends in pharmacotherapy for congestive heart failure at an academic medical center: 1990-1995." Am Heart J 135(3): 367-372, 1998.

9. clinical Practice Guideline Number 11: Heart Failure: Evaluation and care of Patients with Left-ventricular Systolic Dysfunction. Rockville, Md. US Dept. of Health and Human Services, Agency for Health care Policy and Research. 1994, AHCPR Publication no. 94-0612.

Figure 1.
WellStar Health System
CHF Outpatient Case
Management Annualized
Utilization Rates
Admissions and ER Visits
                  Admissions  ER Visits
Before Case Mgmt  2.27        2.09
After Case Mgmt   0.5         0.51
Note: Table made from bar graph
Figure 2.
WellStar Health System
CHF Outpatient Case Management
Minnesota Living with Heart Failure Scores
          Emotional Scores
Baseline  12.5
1st Qtr   9
2nd Qtr   8.5
3rd Qtr   7.8
4th Qtr   7.7
Note: Table made from bar graph
          Physical Scores
Baseline  21.6
1st Qtr   15.7
2nd Qtr   17.7
3rd Qtr   14
4th Qtr   16.7
p [less than] .05 for changes from baseline for
both sets of scores.
Lower values indicate improved outcomes.
Note: Table made from bar graph
Figure 3.
WellStar Health System
CHF Outpatient Case Management Program
Utilization of A CEI/Alternate Drug Therapies
n=246 Patients
ACEI or Acceptable/      89%
Appropriate Alternative
Other Tx                 11%
Note: Table made from pie chart
Figure 4.
WellStar Health System
Patient Satisfaction Survey Results
CHF Outpatient Case Management Program
                                  Percent Favorable Rating
1. Contact with Cease Manager               100%
   Helpful
2. Better Able to Understand and            100%
   Manage My Heart Failure
3. Recommend to Others                      100%
4. Able to Avoid Hospital or ER              80%
Note: Table made from bar graph