Does this sound familiar? Mr. Garza has been admitted four times in the last six months for heart failure (HF) exacerbation. He struggles with medication adherence, meal choices and transportation for outpatient (OP) care. As a case manager, I see many “Mr. Garzas” on my cardiology service line every day. With the advent of pay for performance, the case management focus is on the readmission rate, patient adherence/self-care, and reimbursement. In addition to changes in CMS reimbursement, consider these issues that impact our case management role:

• Approximately one in four HF patients with Medicare are back in the hospital within a month.
• Forty percent of readmissions are avoidable.
• Improved diagnostics and better medications have increased survival for HF patients.
• Greater than 40 million Americans are uninsured or underinsured.

In addition, with increased survival comes quality of life issues and challenges with mental health, such as depression, in a chronic illness that is often accompanied by other health concerns such as diabetes, hypertension, and hyperlipidemia. Case managers face multiple opportunities when working with HF survivors and their families/caregivers. Let’s examine several acute care/inpatient and outpatient care strategies where case managers impact HF outcomes and survivor adherence.

Inpatient/Acute Care

The shift in CMS reimbursement from a passive payer to value-based purchasing has opened multiple opportunities for case managers to impact clinical outcomes. The clinical quality metrics, or core measures, must be attained to maximize reimbursement, or providers risk penalties for non-achievement of these CMS indicators. The HF core measures are:

• Ejection fraction measurement.
• Smoking cessation counseling.
• ACE/ARB prescription.
• HF specific discharge instructions: weight monitoring; symptom management; proper diet; physical activity medication management; and outpatient care.
• HF readmission in less than 30 days.

How do we as case managers impact HF core measures with our providers and survivors? Our interventions can include early patient assessment to identify barriers to self-care and transition to outpatient management, awareness of health literacy in our populations, funding/payer sources, and ongoing collaboration with transdisciplinary team members such as the dietitian, physical therapist and pharmacist. A proactive approach is essential for timely planning and facilitation of CM interventions. Awareness of health literacy leads to effective patient/family/caregiver education and appropriate teaching materials. Healthcare funding determines access and adherence for an HF survivor. No prescription coverage or being a self-pay patient greatly impacts clinical outcomes and self-care. We must be mindful of the health plans and resources for our HF survivors so that we coach them to maximum wellness.

In my facility, the electronic medical record (EMR) is key to our tracking the core measures, the data collection and reporting to our stakeholders. We are able to embed the core measures with the order sets; use “hard stops” to improve provider compliance; and produce HF-specific discharge instructions. The EMR prompts the medical and nursing staff to achieve core measure attainment. In addition, we developed an HF Home Care Plan that addresses the elements of the discharge instructions (see above). I can easily review current orders and discharge instructions from any EMR computer in the hospital. Future plans for our EMR include improved interface with our outpatient providers and service lines.

Transitions to post-acute care may include outpatient cardiac rehabilitation programs, home health services, IP rehabilitation, or hospice care. Examine your community’s post-acute providers for appropriate serves with HF survivors. Outpatient programs and home care providers have developed HF-specific programs to address their unique needs and challenges. Inotropes, such as dobutamine, will require trained providers with this specialty infusion. Hospice is appropriate in HF care when medical management has exhausted all aggressive options and the patient is not a transplant candidate. Regardless of the post-acute care, the case management process includes coordination with funding sources and resources for care that may not be included in a benefit/policy.

Outpatient/Post-Acute Care

Acute care stays are short, and successful transitions to the outpatient setting are essential. Medication management and patient education will most likely occur outside the inpatient setting. HF survivors must know whom to access, such as a primary care physician or cardiologist, for outpatient care. Will they attend a nurse-centered HF clinic? Our outpatient HF coordinator staffs a clinic where self-pay or underfunded patients can receive health assessments, medication management and acute interventions, if needed. The clinic is co-located with the offices for indigent health funding, social work and prescription assistance which is convenient for multiple appointments in one location. This approach offers access to outpatient care and addresses HF readmissions and avoidable inpatient days.

In addition, home care services with home monitoring/telehealth may be a component of an HF survivor’s self-care. Home monitoring allows an HF survivor instant feedback on their adherence and promotes self-care. Weight, blood pressure and other measures are transmitted via phone line or wireless technology to a healthcare provider or central monitoring center. Patient selection, education and an available phone line are keys to successful home monitoring. Providers receive data which can be translated into management strategies and communicated to the patient, family or caregivers.

The ability to adjust medications or provide health instruction may save a visit to the ER. Successful self-care at home may include home modifications and energy conservation techniques. Physical and occupational therapists offer expertise in home safety, activities of daily living accommodations, and assistive devices. Pacing activities during times of maximum energy, as well as allowing for rest periods, will assist the HF survivor to be independent in their personal care or other activities. Simple strategies like moving frequently used items to the bottom shelves, or wearing clothing with snaps, can make a difference.

Other community services may be necessary for an HF survivor to safely live in their own home. These include chore services, personal care aide or transportation services. Your locality may offer these through a variety of agencies such as an Area Agency on Aging. Many services that HF survivors may need are not described as medically necessary and therefore are not funded by a healthcare benefit. Case managers are mindful of the health plan dollars as well as the patient/family/caregiver ability to self-pay. Explore if there is long-term insurance or a VA benefit available, as both have funding for home care services.

Case management strives for safe, appropriate, seamless transitions across all levels and locations of care. Documentation of case management goals and plan, plus the providers involved, offers the HF survivor vital information. Communication from the inpatient to outpatient/post-acute setting provides key data for the transition, whether by phone, fax, encrypted e-mail or EMR.

Final Thoughts

HF management has evolved to a focus on cost-effective quality outcomes with a reimbursement system that pays for achieving HF core measures. Other areas of interest include:

• How do we sustain adherence/self-care in our HF survivors?
• Future technology such as implantable sensors with wireless transmitters.
• Use of healthcare coaches or nurse navigators to intervene for symptom management.
• Will there be a shift in paying for wellness vs. sick care for chronic disease?
• What is the impact of social networks or PC applications on self-care?

Elaine Miller, MSN, RN-BC, is a case manager for Cardiology/Pulmonary Critical Care Services at the University Hospital in San Antonio, Texas, and a member of the CMSA Education Committee. (elaine.miller@uhs-sa.com)