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Readmissions reduced for heart failure patients
Health coaches, home health provides support
A proactive approach to hospital readmissions by Health Alliance Plan (HAP) resulted in a 14% decline in readmissions for heart failure in the Medicare population when compared to the previous year.
The program includes phone calls from nurse health coaches, visits from home health nurses who work on medication adherence, and tele-monitoring for patients at the highest risk for readmission.
"Our population is aging, and chronic health conditions are increasing," says Pat Slone, RN, CCM, manager of clinical care management for the Detroit-based insurer. "We take a high tech, high-touch approach to providing care transitions for members who have gone from the outpatient clinic setting to the emergency department to the inpatient setting, and are discharged back home. Rather than waiting for claims to come in, we use our authorization software program to identify patients who are being discharged with heart failure."
HAP continuously assesses the population with chronic health conditions and then assigns patients at high risk to a nurse health coach who evaluates the patient's eligibility for a tele-monitoring device. "We send a self-management plan of care to all our heart failure patients and encourage them to take it to their physician's office so the doctor can go over the medications and outline what symptoms indicate the patient should call," Slone says. "We give them an educational tool that shows the signs and symptoms of heart failure, self management activities, and has a place for the patient to enter his or her laboratory values."
The health plan calls the case managers who work in this program "nurse health coaches" and provides comprehensive training on helping patients manage their chronic conditions. The nurses are notified when patients are discharged and call patients within 48 hours after discharge to discuss their discharge plan. "Patients are still pretty ill when they're just gotten out of the hospital, so we make this a very focused phone call. The health coach reconciles the medication the patient is reporting at home with what the physician prescribed during the hospital stay, ensures that the member has a follow-up appointment with a primary care physician or cardiologist, and makes sure home health services are in place," she says.
If the patient hasn't scheduled a follow-up visit with a primary care physician or cardiologist or hasn't filled his or her prescriptions, the nurse finds out why and works to overcome the barrier. If they don't have home care ordered, the nurse finds out why. If the patient has refused home care, the nurse tries to convince the patient to accept it.
HAP arranges for in-person medication consultation by Henry Ford Home Health Care nurses. During the visits to the patients' homes, the home health nurses explain their prescriptions, check for duplication, and consult with doctors if there are questions. HAP has found that it typically takes 5-10 sessions, a combination of in-home and telephone interventions, to ensure that patients are taking their medication correctly. "Heart failure patients have multiple prescriptions, and sometimes when they are confused about what to take [and] when, they take nothing and end up back in the hospital. The home care nurses conduct face-to-face medication reconciliation, teach patients how to take their medication, and even help the patient organize the medications," Slone says.
Once the patients are stabilized, the nurse health coaches complete a lengthy telephonic assessment. "Most of the time they're too ill for a lengthy initial call, and we don't want to take so long when we call them the first time that they won't take another call from us," Slone says.
The nurse health coaches call the patients regularly and reinforce their discharge plan. They educate them on the importance of a low sodium diet, the reasons for weighing themselves daily, their exercise plan, and signs and symptoms of an exacerbation. "Sometimes they are so ill, they can't stay on the phone very long, but the nurse starts teaching them to recognize the early warning signs," Slone says. "Nobody wants to be readmitted to the hospital. The nurse health coaches start emphasizing that patients can stay out of the emergency department if they start self-monitoring and call their doctor when they start to gain weight or experience swelling."
The health plan uses an in-home tele-monitoring device for appropriate at-risk patients. Patients have to be able to stand on the scale and be able to read it, and they must have a telephone land line to hook up to the device. The device is delivered to their home, and a technician talks them through installing it.
Patients enter their weight and any symptoms they are experiencing into the monitor and answer a series of question. The HAP nurse is alerted when symptoms show that a patient is at risk. "By accessing the information supplied by patients, the tele-monitoring nurse can see at a glance who is high risk and get their diuretic adjusted before their symptoms get so bad they end up in the emergency room," Slone says.
The health plan takes an interdisciplinary approach to managing chronic disease and integrates the program with behavioral medicine care managers and pharmacy care managers. HAP offers every member in the program the opportunity to have a conversation with a behavioral health case manager. "Many people with chronic health conditions experience depression and anxiety. The nurses screen the patients for depression and anxiety and provide some education over the phone. We offer them a referral to a specialist if their scores are high," she says.
The behavioral health case managers and nurse health coaches work on the same floor and often consult with each other on care for the patients. "It takes a team to manage patients with chronic conditions. We collaborate to make sure patients get what they need to keep their chronic conditions under control," Slone says.
When they transitioned from case manager to health coach, the nurses underwent three days of intensive education that included training on motivational interviewing, workshops by certified health coaches, a practicum exam, and a written exam. "Our nurses are very skilled at assessing patients' readiness to change, finding what motivates patients to change, and weaving that into a care plan," Slone says. For example, a woman with heart failure was very resistant to weighing herself daily. After several sessions, the nurse health coach found that the woman was obese as a child and her mother forced her to weight herself.
"Once the nurse health coach got to the core of the problem, the woman began to move beyond her aversion to weighing herself and began to self monitor her condition," Slone says.