DorlandHealth

With rising health care costs and greater longevity of people living with chronic diseases, case managers must provide services that are cost-effective and that improve a patient’s quality of life. As a nurse case manager at Memorial Sloan-Kettering Cancer Center, I work with patients with systemic AL amyloidosis.

Amyloid is a group of diseases in which abnormal proteins deposit into one or more organ systems, most commonly involving the heart and kidneys. Patients diagnosed with amyloidosis involving the heart have a median survival of 13.2 months. Common presenting symptoms are suggestive of congestive heart failure—shortness of breath, fluid overload and hypotension. Amyloid patients have frequent clinic and emergency department visits as well as hospital admissions due to complications. In addition, patients may be required to attend clinic solely for the purpose of monitoring vital signs and weight. Patient compliance with self-monitoring of fluid status, orthostatic vital signs, weight and salt-restriction is also critical to improving performance and medical status.

Working closely with this population in the inpatient setting, one of the most critical questions was how to reduce patient burden with frequent travel to health care settings and repeated admissions. The answer was found by implementing a telehealth monitoring (THM) case management disease program. THM is an electronic device that allows patients to monitor vital signs like blood pressure and pulse, weight and oxygenation status at home. Data are transmitted by Web-based programs in real time. Clinicians can make home-based interventions by telephone triage and by utilizing the home care nursing services associated with the THM agency. Such interventions can include medication management, fluid balance management, and patient education to respond to changing clinical situations. Empowering patients to understand their disease process and manage disease-related symptoms, clinicians can help patients prevent the escalation of symptoms that might otherwise require admission to an emergency department or clinic.

I was inspired by a 39-year-old single mother who spent significant amounts of time in the hospital, preventing her from being with her 5-year-old daughter. We began to collect feasibility data in November 2007 by interviewing amyloid patients, evaluating the reasons for admissions, performing retrospective chart review, and contacting managed care companies for telehealth coverage and home care agencies who provided this service in the demographic areas our institution served.

A pilot project launched in July 2008 with the collaboration of the hematology service for patients with significant symptoms of congestive heart failure and post-chemotherapy symptoms. A digital monitoring system was placed in the patients’ homes, which allowed them to take their vital signs and weight in convenience and privacy.

Frequent follow-up calls were made by the case manager and office practice nurse to reinforce medication compliance and emotional support, and to address any psychosocial issues, such as lack of understanding of medication regimen, noncompliance with diet, and depression and financial issues. Appropriate referral services were initiated.

THM has proven to be an effective home management strategy. It reduced patients’ travel burden, identified problems sooner, and reduced clinic and emergency department visits. Nine patients have participated in this pilot. For the six patients who have been enrolled in the program for an average of four months, emergency room visits have decreased by 42 percent, readmissions by nearly 13 percent, and clinic visits by 38 percent. Effective early symptom management has improved the quality of life of the patients who have participated.

“In this day and age of health care reform we need to constantly look at ways to save dollars. We feel that this project sets us on the right path of cutting costs but at the same time continue to provide quality care to a unique and complex group of patients,” says Mary McDonough, RN, MSN, CCM.

Although the sample size is small, this pilot demonstrates successful home monitoring of a tenuous cancer population. This pilot continues to enroll patients and we plan to expand to additional cancer populations.