Title: Case management of Patients with CHF
1Case management of Patients with CHF
- Presenter
- Claire Prentice
- Clinical Nurse Coordinator
- Surrey Memorial Hospital
2Case Management
- Definition developed by CMSA
- a collaborative process which assesses, plans,
implements, coordinates, monitors and evaluates
options services to meet an individuals health
needs through communication and available
resources to promote quality, cost-effective
outcomes - ( Huber, D Ph.D, RN, FANN, CNAA The Divesity
of Case Management Models Lippincott Nov./Dec.
2002 )
3- Case Management
- Is experiencing rapid growth and evolutionary
transition. - There are a diversity and richness of case
management models found in practice. - generally manages risk and coordinates care as
core functions, what is actually done beyond this
is highly variable - Is both disciplinary and interdisciplinary. No
discipline owns it multiple disciplines are
involved.
4- Many types of models with many labels presented
in the literature. - Social
- Primary care
- Medical/social
- Independent
- Insurance
- Direct care model gap/filling model
- 3 types of CM in Nursing
- Hospital based
- Hospital community
- Community - based
5- Nursing and healthcare models tend to focus on
the management of the health/illness, disease, or
rehabilitation needs of an individual or
population. - The use of CMPs has successfully
- Contained health care costs
- Reduced LOS
- Improved quality of care
- Streamlined use of resources
- Opened communication lines among healthcare team
members
6Surrey Memorial Hospital Heart Function Clinic
- In operation since 1996
- Nurse managed cardiologist directed
- Serves heart failure clients in the North and
Central Surrey Region - Operates once weekly for 4 hours
- Nurse available Mon Fri and after hours for
crisis management, telephone follow-up - New patient referrals vary from year to year
- 98- 103 99 85 2000 71 01- 61 02
19 - Repeat visits
- 98 456 99 443 2000 320 01 311 02-
214
7Nurses Role in the HFC
- Promote and monitor health, alter tx PRN
- Provide emotional support to clients and family
- Education on nutrition, medications and activity
- Telephone follow- up and crisis management on a
need basis. - Facilitate end of life care
8- PROGRAM OBJECTIVES
- Improve QOL for patients family
- Reduce LOS and ER/hospital admiss.
- Promote patient self management of their chronic
disease process - Provide education for the caregiver/ family about
the care of patients with HF - Create a linkage with Palliative Care
- Establish a centre for coordination of clinical
trials for HF - Establish accurate data collection
9Case management Processes
- Patient Selection Process
- Physician referral required -GP/Cardiologist
- 2 pathways of referral education vs education
and medical management - Documented evidence of HF required
- - Echo, MIBI, MUGAs ECG, Cath
- recent labs and BNP ( if available )
- Recent admission to hospital with HF
- NYHA Class I-IV
10Communication Process with Physician
Notification of 1st visit date with explanation
of purpose of clinic Consult from Clinic
Cardiologist on 1st visit Summary of changes
done at each visit sent to GP labs, clinical
findings, referrals to other disciplines and
specialists, issues
for them to follow-up on. Discharge
notification sent along with latest medication
record.
11Documentation and Monitoring Tools Patient
summary form Admission
Assessment Physician flow sheet
Education documentation sheet Patient care flow
sheet Lab flow sheet Telephone contact
sheet SMH Physicians order form
Medication flow sheet Medication
history record. Patient brochure Medication
record wallet card Low salt guide info Medication
information sheet CHF Booklet- Living with
Congestive Heart Failure Personal Action Plan
form
12Patient Education Process NYHA Class I-II
education only - of visits dependent on patient
level of understanding NYHA Class II-IV
education and medical management patient is
seen on a regular basis ( q weekly ) if necessary
for close medical follow-up and education.
13Patient Education Process ( contd ) Education
Focus each visit on the following etiology of
heart failure, recognizing signs and
symptoms of worsening HF importance of daily
weight and fluid balance. low Na diet,
exercise, energy conserving mechanisms
medication compliance. Self management goals
are initiated documented on PAP
reinforcement of patient specific education
needs done on each visit
14Protocols or Standing Orders Canadian Guidelines
for the Management of Congestive Heart Failure
Beta blocker titration goals Diuretic
titration goals Referrals to other disciplines
Ie, dietician, social worker, physio, OT, Home
Care Nursing for follow up, assessment for
placement as required. IV Lasix infusion in
Ambulatory Day Care. IV Lasix infusions in the
community
15- Protocols and Standing Orders ( contd )
- BNP level drawn on admission, discharge and in
the decompensated patient. - Discharge criteria as a standing order
- Improvement at least 1 functional class
- Patient clinically stable as evidenced by stable
weight, and no overt findings of HF in the last 2
visits. - Patient has met his education outcomes
- Patient is on all proven therapy with maximal
tolerated dose obtained.
16Responsibilities of the Case Manager.
- Refer pts. to the clinic from the hospital or
community with agreement of cardiologist. - Demonstrates and performs advanced physical
assessment skills along with providing emotional
and spiritual support to patient and family
members. - Provides education on heart failure management
and reinforces with the patient on an ongoing
basis.
17Responsibilities Contd
- Facilitates development of patient self
management goals - Follow up on patients between visits on
clinical status, medication titration, lab and
diagnostic test results and to provide crisis
management for de-compensated patients. - Assesses and facilitates referrals for other
health disciplines - dietician, social worker, OT, physio in hospital
community, chaplain, palliative care, home care
support.
18Responsibilities contd
- Acts as a clinical role model and resource for
other nurses and disciplines. - Assists in the ongoing maintaining and
evaluation of the program with implementation of
Quality improvements as required.
19What are the key elements for successful case
management?
- A good working relationship between clinic nurse
physician. - Strong knowledge base of disease process
- Excellent assessment skills.
- Strong patient advocate
- Being a good listener
- Aware of hospital and community resources
- Facilitation of patient education and constant
evaluation and reinforcement. - Promotion of patient self management.
- Sense of humour / sensitive to cultural
differences
20 3 most important things I learned about
implementing CM
- Good communication skills are crucial both verbal
and non verbal. - Maintaining a positive and caring environment for
clients - The promotion, facilitation and support of
patient self management skills. - Looking at the patient as a whole being and
facilitating their emotional, spiritual and
physical well being - Good working relationships and knowledge of
duties of other disciplines.
21What barriers to case management have you
experienced?
- Limited resources and or time for consistent
follow-up of patients in the clinic setting - Limited resources in the community ( ie home care
nursing ) to better assist patient independence
and compliance of treatment or to assist family
with patient care when condition worsens. - Lack of primary care physician involvement as a
team member in the patients care. - Lack of data base to track outcomes and/or
resources to facilitate obtaining this
information
22END
23Mid Main Community Health Centre
- Multi-Disciplinary Clinic established in 1988
- (medical, dental, nurse clinician, clinical
pharmacist, - part-time pediatrician)
- Located on the east side of Vancouver
- Highly diverse patient population
24Primary Case ManagerDiane Middagh
- Multi-Disciplinary, team oriented, primary care
clinic - Case management based on working within a team
setting - Establishing CHF registry
- Routine audits of registry and charts
- Creation of menu of intervention for physicians
utilizing CHF guidelines - Initiation of planned visits
25Case management of Patients with CHF
- Weekly meetings with members of the primary care
team - Planned visits within the clinic or in patients
own home - Patient education regarding CHF, salt intake,
fluid restriction - Baseline education for everyone in the registry
26Objectives
- Education regarding the term CHF
- Lifestyle discussions
- salt, fluid, activity, smoking
- Self-management goals
- Daily weights
- Salt and fluid intake
- When to phone clinic (palpitation, fluid
overload, SOB) - Medication titration
27Case Management Processes
- Nurse and pharmacist takes F/U lead
- Planned visits
- Initially as often as required, then bi-weekly x
2, then monthly, then quarterly - Protocols or standing orders
- None implemented as yet, lots of informal
discussion - Patient selection process
- All patients in registry require initial planned
visit - Communication with physician
- Through the menu of interventions and face to
face discussions
28Case Management Process (continued)
- Documentation and monitoring tools
- The registry and the patient chart
- Patient education process
- 11 sessions
- Patients pamphlets
- Evaluation Process
- Were not there yet, monthly data reports and
then discussion
29Tools to support the process
- Flow sheet
- Use of the provincial CHF guidelines
- Educational materials
- Healthy Heart Program patient handouts
- salt and fluid handouts
- Ministry of Health flow sheets
- collaborative flow sheets
- scales
- Supportive team environment
- Weekly primary care team meetings
30Team Environment
31The key to successful case management
- Supportive team
- Buy-in from all members of the team
- Administrative support
32The three pearls of wisdom about implementing
case management
- Supportive team environment
- Office systems
- Successful patient outcomes
33Barriers to case management
Too much work not enough time
34Questions?
35Contact Info
Diane Middagh Primary Care Nurse
Clinician 604-873-3666, extension 248 E-mail
midmaindocs_at_telus.net