Journalists often write a story about the next new thing, go on to the next new thing, and never double back to see just how that old new thing worked out. So I decided to revisit a story I wrote in the spring of 2009 for the Washington Post/Kaiser Health News, exploring what was then the relatively new topic – outside the research and policy world – of reducing hospital readmissions.
At the time, the congestive heart failure management program at Mount Vernon Hospital in Alexandria, Va. was small, and up and running in only one of the five Inova hospitals in Northern Virginia. Now it’s spread to four hospitals – but open to patients in all five (one heart program covers patients in two of the hospitals). The hospitals like it, the patients like it, the nurses like it, and according to some of the nurses who run it, more physicians are referring their patients to it.
“The doctors say, ‘follow this guy too or he’ll be in the hospital,’” said Penny Kardis, R.N., M.S.N., one of the nurses in the Fairfax HeartLink program.
The data I’m sharing here is imperfect. No peer review (as far as I know). Comparing patients in the CHF management program and those who are not is like apples and oranges, both because they don’t necessarily have the same acuity and also because there is a degree of self-selection. Patients choose whether or not to participate in the program, and whether to stick with a program that involves a degree of self-care and consistency.
But that doesn’t mean the statistics they do have – and the buy-in from the hospitals – doesn’t pack some punch. According to the Fairfax nurses, Kardis and Marie Taubman, R.N., M.S.N., patients are highly satisfied (93 percent say care is good, including more than 60 percent rating it very good or excellent). Hospital readmissions in the HeartLink group versus regular care are lower – enrolled patients had 1.05 fewer admissions then those not participating. And when they do get readmitted – and even well-managed CHF patients sometimes need readmission – they aren’t as sick, and don’t stay in the hospital as long. “An enrolled patient’s length of stay is 1.5 days shorter, and that saves about $2,052 per admission,” Kardis said. HeartLink is free to patients, and Medicare and insurances in the current fee for service system rarely cover such services, but that shorter length of stay can save the hospital money.
“The patient doesn’t pay, the hospital takes on that financial responsibility,” Kardis said. “But if you manage a patient – it costs much less to follow a patient than to have them in the hospital for a day.”
Under some of the new care models encouraged by health reform, such as a medical home, accountable care organization, or bundled payment system, the financial incentives would line up differently, potentially making programs like this one even more cost-effective. Also once hospitals with particularly high readmission rates start getting penalized (for admissions in the 2012 fiscal year), more may turn to these monitoring and management models.
Here’s how the program works in a nutshell, and then I’ll describe what some may find a bit surprising about its success – and one challenge the nurses described.
When a CHF patient is admitted to Inova, one of the HeartLink nurses makes a personal contact, describes the program, invites them in, etc. (Only about 27 percent of the patients who are referred to the program accept, which is something the program is working on. Once in, 79 percent remain engaged for at least 30 days.) Every weekday, the patients place a telephone call to an 800 number, answering five questions about weight gain, swelling, and difficulty breathing. If everything’s OK, nothing happens. If there’s a warning sign, the nurses monitoring the computerized responses see it. They call the patient.
On any given day, roughly 10 percent of the patients – 15 or 20 of the 155 who were in the Fairfax Inova campus where HeartLink began in 2009 – have one or more symptoms that need attention. That’s usually an adjustment in diuretics or other medication. (There’s a protocol in place for how the nurses and the cardiologists’ offices do this). Sometimes the patient should see his or her doctor quickly – and the nurses, with their relationships with the primary care physicians and cardiologists, can ensure that happens, so that the patient isn’t given an appointment in a week, vastly increasing the risk of a setback, a complication, a visit to the emergency department, a hospitalization, perhaps a stay in the coronary intensive care unit.
“We get them to call their primary physician,” said Kardis. “Or we call to get them in.”
“One of the changes the nurses have seen is that doctors are referring patients now BEFORE they end up in the hospital. That’s a much more proactive approach, as doctors are recognizing that the patient would benefit from HeartLink,” Taubman said. Patients can also self-refer.
One of the things that interested me about this program is that it’s phone-based, with a computer program bought from an outside vendor (and in use elsewhere.) And as I have read and learned about hospital readmissions and disease management, I had come across studies and research that had suggested that phone-directed disease management wasn’t that successful, that programs with at least one home visit (usually by a nurse) had a better impact on readmissions, partly because of the extra personal touch, partly because medication reconciliation is much easier to do once a nurse is in the house and can see what’s piled up (and what’s missing) in the medicine cabinet, bedside table, shoeboxes in the kitchen, etc.
At Inova the phone approach without the home visit seems to be working. That may be because the nurses (and one physical therapist involved at one of the Inova HeartLink programs) are associated with the patient’s local and familiar place of care. The patients are dealing with the same small group of providers, so they have continuity. The nurses and physical therapists I spoke to, at Fairfax this time and at the Mount Vernon site a few years ago, all spoke about the personal relationships they’ve established, mostly on the phone but often also in person through the initial hospitalization and with the patients who come in for ongoing cardiac rehab programs. They all described using those phone calls not just for a quick adjustment to the diuretics, but for teaching moments about CHF management, including diet and nutrition and sodium intake. While they are at it, they help patients learn about and take care of the other chronic conditions many of them have, including diabetes and renal failure.
“They get to know us,” said Taubman. “And we get to know about them,” added Kardis. “We get the whole scoop.”
And although patients have a choice of whether to enroll in the program or not, those that do are not necessarily the perfectly “compliant” patient who already has the disease under control. “We spend a lot of time with patients who aren’t eating properly or paying close enough attention to edema or weight gain,” Kardis said.
“The personal relationship with the patient makes the difference,” said Taubman. “We can see the changes as individual patients become more compliant … You can see the changes in the individuals over time.” Patients learn to monitor their weight and respond to fluid accumulation.
That doesn’t mean every patient is a success story. Some who don’t call in and participate regularly may leave the program. On the other hand, some learn to be so consistent and good at self-care and knowing when to get help that they meet their goals and are discharged from HeartLink because they no longer need the daily checks. The disease is progressive so patients can opt back in if over time they get to a point where they need more monitoring and assistance. Most will eventually get sicker from their CHF; some will eventually die even if they are working closely with the HeartLink team. Even a well-managed disease may eventually take its toll.
One priority for the team is trying to figure out how to get more CHF patients who are admitted to Inova who are eligible/suitable for HeartLink to sign up – i.e., to improve that 27 percent acceptance rate. Right now patients may not understand how high their risk is for repeat episodes of severe shortness of breath and the resulting hospitalizations, or how much they can lower it. In addition, they may already have so many doctors and regimens in their life that they don’t want to add another. And this particular service isn’t a good match for patients with dementia or cognitive problems, unless they have a family member or caregiver to help out with the daily checks.
Inova is looking into other aspects of “transitional medicine,” following patients for 30 days after a hospitalization. That’s not part of this CHF program per se, but the nurses with experience with the heart disease follow-up have been a resource for their counterparts developing the other programs that will aim to build better bridges between the hospital and community-based care. That will be the focus of a lot of the innovation and “curve bending” in the years to come.
Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.