Congestive Heart Failure Disease Management Program

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Congestive Heart FailureDisease Management
Program
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Project Goals

• Coordinate and strengthen healthcare services for
  patients with chronic disease, in particular,
  Congestive Heart Failure
• Provide clinical preventative services that are
  proven effective in managing chronic disease
• Utilize Patient Navigator services to support
  coordination of care with hospitals, physicians
  and clinics that provide treatment and primary
  care

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Primary Activities

• Implement a CHF disease management program
  utilizing the CareEnhance Call Center software
  and utilizing the CHF module of CECC
• Coordinate services and activities that are
  complementary across hospitals, physician offices
  and clinics
• Use telephonic outreach to promote patient self
  management
• Target Service Areas Harris County and Fort
  Bend County

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Eligibility

• Patients must
• Be 18 years of age or older
• Reside in Harris or Fort Bend County
• Have a confirmed diagnosis of CHF
• Be uninsured, underinsured or
• Be a recipient of Medicaid or
• Be a recipient of Medicare and not currently
  enrolled in a Medicare Demonstration Project
• Agree to a primary health home for ongoing CHF
  management

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Referrals

• Referrals come from any hospital within Memorial
  Hermann
• Initial pilot at Memorial Hermann Southwest
• Referrals may be submitted by an clinical staff
  member or primary care provider
• Referrals need to include pertinent clinical
  information related to the specific needs of the
  patient

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Program Scope

• The program will not provide any direct treatment
• Patients will be introduced, whenever possible,
  to the program while the patient is still in the
  acute care setting
• Program participation is voluntary
• Interventions will be handled telephonically
• There may be limited occasions where a home visit
  is warranted and this is done at the discretion
  of the RN case manager
• Program will utilize both patient navigators and
  case managers

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Program Scope

• All patients will have an assessment completed by
  an RN case manager
• Based on the assessment, patients will be risk
  stratified
• Patients stratified into the high categories will
  continue to receive contacts from RNs
• Patients stratified into the lower risk
  categories may be referred to patient navigator
  for follow up

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Implementation

• First three patients accepted October 17, 2006
• Currently 128 patients enrolled
• Response and compliance is improving

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Program Results
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Anecdotals

• Patient enrolled in Jan, 2008. Since enrollment
  patient has taken a very proactive approach to
  health. Patient and spouse are both following
  low sodium diet, weighing daily, monitoring blood
  pressure and recording results daily. Patient
  mails the CM a copy of the log, and takes this
  information to regularly scheduled physician
  office visits. No hospital readmission since
  January. The patient was visiting the hospital
  once every 4-6 weeks prior to program enrollment

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Anecdotal

• Patient enrolled in September, 2007. Patient had
  been a smoker for 50 years. Since program
  enrollment, the patient has stopped smoking, both
  patient and spouse are adhering to a low sodium
  diet. Patient is monitoring weight and BP daily
  and is compliant with medication administration.
  Patient has not been re-hospitalized since
  September, 2007

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Anecdotal

• Patient enrolled in September, 2007. Patients
  CHF was consistently exacerbated because the
  patient is also diabetic. During the initial
  conversation with the CM, patient stated the
  glucose was not being checked because the patient
  could not afford the diabetic supplies. CM
  worked with the patient to coordinate services
  through a Medicare provider. The patient had
  been unaware that supplies would be paid for by
  Medicare. Patient is now checking blood sugars 4
  times daily, checking blood pressure as required,
  and following a low sodium diet. The patient has
  increased physical activity and is happy to
  report the increase in activity level, as the
  patient is feeling better. No
  re-hospitalizations since September, 2007.

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