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Special scale, monitoring keeps patients in check
A one- to two-pound weight gain in a day signals trouble for congestive heart failure patients, so caregivers instruct patients to weigh themselves every day and call if they experience a sudden gain.
But how accurate are their scales? Can they even see well enough to read the numbers? Do they fear weight gain so much that they imagine the scale says what they want it to? Do they wait a few days before calling to see if the problem resolves itself?
If you ask yourself those questions, chances are you won’t be happy with the answers, and chances are you don’t have the time or the resources to stop your patients from falling into the nationwide gap of 3.5 million CHF hospital admissions per year.
About 20 providers — amounting to approximately 1,000 patients in 30 states — with that same problem are looking outside their organizations to cut CHF hospitalizations and related costs through a weight-monitoring device and related heart failure management program developed by San Francisco-based Alere Medical Inc. The early results are encouraging: Several small studies have shown reductions in hospitalizations of 80% to 84% and patient compliance rates of 90% to 95%. A 17-site randomized trial conducted by Evan Loh, MD, medical director of the University of Pennsylvania’s Heart Failure and Cardiac Transplantation Program, is under way to test these numbers on a large scale.
The Alere program revolves around the DayLink Monitor, a scale platform and communications device that allows patients to obtain at home an objective, accurate daily weight measurement. The information is forwarded electronically to nurses who monitor the results and inform the physician when a problem is suspected, says Jean Corey, RN, MS, director of clinical services for Alere.
Physician controls the program
The patient steps on the scale, which is accurate within 4 ounces and accommodates up to 400 pounds, and the accompanying communications device prompts him or her to answer a series of yes-or-no questions designed to assess how the patient is feeling. The information is transmitted by a phone or Internet connection to nurses who monitor it daily and report problems immediately to the physician.
The program is physician-driven; the physician chooses what questions are asked and at what point he or she wishes to be contacted. Nurses monitor the information daily and, if there’s a problem, send an "alert" report by fax to the physician that shows a graph of the patient’s weight and symptoms in the past 30 days. If the patient is doing well, the physician will receive a routine summary on a weekly or monthly basis. (See sample report, p. 67.) The patient’s daily questions can be changed remotely at the physician’s request, and the data are available to physicians and nurses on Alere’s Web site.
"The distinguishing factor about this program is that we stay on top of the patient’s [condition] daily," Corey says. "We filter the data and transform them into real, true measurements that the physician can use to make an immediate judgment. Physicians don’t get extraneous data, and they find [using the information] lowers their weekend calls."
Alere also offers education services in which nurses will teach patients about their disease by phone, says Jan Barker, RN, FNP, MS, Alere’s vice president of operations. The nurse will begin by calling the patient once a week or more to ask about their symptoms and find out what their knowledge deficits are. They’ll address such topics as recognizing symptoms, understanding medications, and complying with diet recommendations on an individual basis. "Everyone should be educated to his own level and based on his readiness to receive that education," she says. "There’s a huge advantage to the phone system because we can call them frequently and give tidbits of information one at a time. If patients don’t weigh or if they’re getting into an alert situation, we call them and that allows a teachable moment."
A primary nurse calls patients each time if possible, and nurses are working 365 days a year. "This is especially important on holidays and weekends, which is when patients tend to overeat and forget their medications and is also when offices and clinics are closed," Corey says.
Larry Davis, MD, medical director of Quality Care Network in San Antonio, says he’s used the Alere program with patients and likes the fact that he’s still in charge. "The doctor picks the weight gain at which he wants to be notified from a range of three to seven pounds," he says. "I picked five pounds, and I’d be called if the weight went up that much. Each time they called me, it was appropriate, and I didn’t have a single admission. With the Alere monitoring, the doctor doesn’t have to watch the patients as closely and they have less office visits."
Davis says he’s encountered some resistance among physicians who think they will lose control of their patients or have to look at one more piece of useless paper. But Davis says Alere’s program involves very little work on the physician’s part.
"This is a program that allows you to ignore it and it will take care of itself," Davis says. "When those alert faxes come across, they stand out and they don’t get tossed. It’s better for the patients, and it gives you time to see other patients. That’s more time for the doctor and a better lifestyle for the patient."
The daily monitoring and frequent patient contact is what attracted PacifiCare of Texas to Alere’s program, says Carolyn Seabolt, RN, state manager of disease management. "We analyzed Texas demographics and found that CHF was the No. 1 reason for males and females over 65 to be hospitalized. We felt we needed to take action."
So far, the action is working. PacifiCare of Texas began enrolling patients in the Alere program in March 1999 and measured an 84% reduction in hospitalizations after six months. PacifiCare’s baseline utilization data from 1997 showed a 1.6 per 1,000 admission rate for a primary diagnosis of CHF; that rate is 0.3 now.
The health plan currently has 140 members enrolled in the Alere program and also offers a patient education program called "Taking Care of Your Heart Health" that was developed internally. "Effective education is based on empowering the member to take control," Seabolt says. "We give them the tools and the resources they need to manage their health. If you don’t change the patient’s behavior, you won’t change their outcomes."
Minneapolis-based HealthPartners recently signed an agreement with Alere after 10 years of trying internally to make progress in improving outcomes for CHF patients, says Jan Wuorenma, RN, senior director for disease management. Individual clinics had tried implementing telephone monitoring, patient education and distribution of scales to patients who didn’t have them at home with some success, but there was no infrastructure in place to identify patients and measure improvements, she says.
"We knew we could make an impact, but there was a lot of frustration for the staff. They tried for 10 years to progress, and things would always slip back," Wuorenma says. "There was no system in place to keep it going when there was staff turnover. If you don’t build this kind of thing into the way you work, you can’t keep it alive for the long term. In some clinics, only five or six patients are eligible and they can’t afford to do it on that small of a scale."
Having a planwide program makes it cost-effective and also allows early identification of patients. "If you have to wait for the claims data to show who the Class III and Class IV CHF patients are, you’re behind the eight ball. Now we’ve got people watching to proactively enroll patients who have severe CHF so they can stay in good shape."
HealthPartners began enrolling patients in November and had only one hospitalization that might be CHF-related among 80 patients in the first three months. "It’s early to say what the success will be, but we’re hearing anecdotally that patients feel safe now that someone is watching out for them every day," Wuorenma says. "The monitor is very simple so they don’t need any technology or know-how. The scale talks to them, they push a button to say yes or no, and they don’t slip through the cracks anymore. Partnerships today are necessary to improve patient care. You can try to build something like this yourself, but it’s hard to do it quickly and cost-effectively that way."