The coordination of treatment and services for individuals with chronic care conditions is an ongoing issue for the health care industry. Individuals with chronic care conditions account for a disproportionate share of health care expenditures. The Centers for Medicare and Medicaid Services (CMS) has estimated that 57% of fee-for-service (FFS) beneficiaries have congestive heart failure (CHF). CMS estimates that CHF accounts for 35% of total program spending. Beneficiaries with CHF averaged nearly four times the monthly health care expenditures than the average FFS beneficiary. On average, 62% of CHF patients had at least 1 hospitalization annually. It is estimated that half of those patients require readmission to the acute care facility within 6 months, and that 25-35% will die within 12 months. Patients with chronic conditions often receive care from multiple physicians across different care settings, often without a single coordinator. This has prompted the development of disease management strategies aimed toward attenuating associated morbidity and mortality.
Providers of Post-Acute Care services (PAC) are a critical component of managing chronic care conditions. ?Being a part of the continuum of care requires that post-acute providers are an active participant in the coordination of care for patients with these conditions.? said Dr. Greg Basting, Vice President of Medical Affairs at Allied Services Integrated Health System. ?Preventing readmission to acute care facilities during PAC and afterwards is a quality of care goal.? To address the coordination of care for patients with CHF, we developed evidence based self-management program to assist patients in managing their condition after inpatient discharge, or while receiving home-based or outpatient services.
According to the American Heart Association, patients and their caregivers are responsible for the vast majority of heart failure care. Successfully teaching heart failure patients how to manage their own condition is a low-risk, low-cost and effective treatment for these patients. Self-management requires that patients recognize a change (such as increased edema), evaluate the change, decide what action to take, implement treatment (e.g. take an extra diuretic), evaluate the results of that treatment and report to the physician as directed.
Allied Services has developed an evidence-based heart failure self-management program. The program provides the patient basic education about heart failure, its causes, and symptoms. From there we educate the patient on the various medications used to treat heart failure, and the tests used to diagnose and monitor the condition. The program then critically focuses on self-management activities that guide patient behaviors necessary to successfully manage their condition. Patients are taught about how to properly weight themselves, how to manage their medications, proper diet, fluid limits, how to watch for swelling, exercise tips, and oxygen management. Importantly the patient is instructed on ?red flag? signs that should prompt them to call their physician immediately. The self-management program will be integrated into all of Allied Services levels of care so that patients are receiving an integrated, consistent message on how to manage their condition throughout their rehabilitation process.
To supplement the self-management program Allied Services Home Health & Rehab is using telemonitoring technology to manage this condition. Allied utilizes the Health Buddy appliance, awarded best product by Business Week and Best Enabling Tool by the Disease Management Association of America. This technology allows patients and their caregivers to track and transmit blood pressure, oxygen saturation levels and weights via a secure website on a daily basis, providing our nursing staff with information needed for early intervention and improved patient compliance with heart failure protocols.
In addition to these steps Allied Services is developing a systematic, evidence-based method for managing heart failure across the post-acute care continuum. ?As a system, we?ve recognized the need to standardize how we manage chronic conditions such as CHF.? noted Dr. Basting. ?Making sure that we have the best clinical practices for assessment and early intervention in patients with CHF is critical. The objective is to avoid interruption of the rehabilitation process by reducing the transfers to the acute care setting for treatment of CHF. We believe that early intervention and management provides us with best opportunity for keeping patients from returning to the hospital.?