An enhanced heart failure care coordination and management program launched by Independence Blue Cross in mid-2015 is showing encouraging, positive results and decreased hospitalization. The program electronic remote monitoring (telemonitoring) of patients’ vital signs and health care through ReAdmission Solutions (RAS), an independent company, to allow for better coordination of care for patients with heart failure.
Did you know? Heart failure is the leading cause of hospital admission in the United States, and 20% of these patients are readmitted for the same symptoms within 30 days of their initial discharge. However, 12.5% of these hospital readmissions are considered preventable when patients receive the proper information, monitoring, and assistance they need to manage their health. And that’s where our coordinated care initiatives and program step in.
Since its inception, we have been continually enrolling new patients into the program, and are now beginning to see some positive results. Currently we have 2,000 active members in the program, and preliminary results show that the hospital readmission rates of our participating members after 30 and 60 days is trending down and is below the network baseline. We also saw a decline in emergency room visits and the need for other acute care.
The enhanced heart failure care coordination and management program relies on the power of coordinated care. It’s a group effort to ensure trigger symptoms in high-risk patients are closely monitored, physicians have the important information they need on patient vitals before they become dangerous, and that patients receive the quality, personalized care they need. The following case studies show this success in more detail:
Case Study 1: Diuretics and Coordinated Care
Patient History: 70 years old, diabetes, sleep apnea, depression, and congestive heart failure.
Finding: On day 8 of telemonitoring, the patient was noted to have a weight gain of 4 pounds overnight.
Action: RAS called the patient, who reported feeling more short of breath than usual. RAS then called the weekend on-call physician at her cardiologist’s office to relay this information.
Result: The patient was instructed by her physician to double her oral diuretics for the next two days. With the recommended medication changes, the patient’s weight reduced over the weekend and her symptoms resolved. Without the quick adjustment to the patient’s diuretics, her symptoms may have persisted, leading to hospital readmission.
Case Study 2: Hypertension and Coordinated Care
Patient History: 84 years old, hypertension, coronary artery disease, congestive heart failure, asthma, and stroke.
Finding: Telemonitoring showed increasing hypertension.
Action: RAS contacted the patient after she reported having headaches associated with high blood pressure. RAS then forwarded her vital signs and symptoms to her cardiologist’s office, but discovered the specialists were unable to see the patient that day. RAS then notified her PCP, who scheduled her for a same-day appointment.
Result: The patient was instructed to continue taking her four antihypertensive medications, but to adjust the time schedule for the medications based on her telemonitoring trends. RAS reinforced these changes with the patient on follow up calls and now her blood pressure is within normal limits. Without this early intervention, the patient may have experienced continuing symptoms leading to a hospital visit.
Case Study 3: Heart Failure and Coordinated Care
Patient history: 62 years old, congestive heart failure, hypertension, and obesity.
Finding: On day 12 of monitoring, the patient was noted to have a 3-pound weight gain, elevated blood pressure, and decreased oxygen in the blood.
Action: The RAS nurse spoke with the patient, who reported no symptoms aside from shortness of breath on exertion. Heart failure education (fluid restriction, low sodium diet, etc.) was reinforced with the patient. The vital signs were relayed to the patient’s cardiologist, who saw him the next day.
Result: Medication changes were made and the patient now has stable vital signs.
Case Study 4: IV Lasix Treatment and Coordinated Care
Patient history: 80 years old, history of congestive heart failure, COPD, CAD, and sleep apnea.
Finding: During check-in calls, patient complained of swelling and shortness of breath on exertion, which was confirmed by her home care nurses.
Action: The RAS nurse informed the patient of the possibility of receiving IV Lasix (Furosemide) at the a skilled nursing facility. The RAS nurse contacted the patient’s PCP and relayed the patient’s concerns about this possible treatment. The patient received a home visit from her PCP, who then called the skilled nursing facility and ordered IV Lasix for the patient. RAS coordinated with facility and the patient to make sure the patient was adequately prepared for what to expect (transportation time, the need to bring an overnight bag and home medications, etc.). The patient was admitted, received 40 mg of IV Lasix, and stayed overnight for monitoring. She was transported home the following day via free shuttle provided by the center.
Result: The RAS nurse spoke to the patient, who was thrilled with the care she received. She noted a significant decrease in her lower extremity swelling and a great improvement in her breathing. Instead of readmission to the hospital, she received care in a familiar, comfortable environment with improved symptoms.
Case Study 5: PACE Qualification and Coordinated Care
Patient history: 64 years old, diabetes with insulin pump, congestive heart failure, hepatitis, and leukemia (in remission).
Finding: The patient reported that he had not seen his PCP or cardiologist in more than a year. He also reported difficulty affording medications. Upon being placed on telemonitoring, he was found to be extremely hypertensive.
Action: The patient was referred to a social worker, who is assisting him with a PACE (prescription assistance) application to afford medications. RAS notified the cardiologist of our findings and faxed him the telemonitoring trends.
Result: The physician outreached to the patient to review his medications and made an appointment for him to be seen. Affordability is a major factor in medication compliance, so helping the patient qualify for PACE is an important step to getting his symptoms under control and avoiding potential complications.
Case Study 6: Early Symptoms and Coordinated Care
Patient history: 62 years old, congestive heart failure, diabetes, hepatitis, heart attack with stents, renal insufficiency, and sleep apnea.
Finding: Telemonitoring was installed and the patient was found to be hypertensive with blood pressures trending up daily.
Action: RAS notified the cardiologist’s office with the patient’s telemonitoring trends. The RN at the physician’s office called RAS to review the patient’s medications, which were verified.
Result: The patient was brought in the same day for an appointment with the cardiologist, who also scheduled him for a follow up appointment with his nephrologist to discuss medication changes. By reacting to the patient’s symptoms early and evaluating medication changes, the patient avoided a potentially serious health crisis and possible hospital readmission.
As we continue to monitor patients participating in the enhanced heart failure care coordination and management program, we are excited to see a positive effect on the health and well-being of this population, and to optimize the program for even greater results in the future.