BY CATHERINE M. MULLAHY, RN, BS, CRRN, CCM
Case managers especially demonstrate their value when caring for patients with complex medical conditions. This is true for patients with congestive heart failure (CHF), which is among the more serious conditions for patients and their families. It is in these cases that the role of the case manager and the implementation of best-in-class practices are critical. As part of that role, there are many dynamics at play, including communications with the patient and family members to assure adherence to the treatment plan, communications with other professionals across multiple disciplines on the care team, ongoing patient follow-up, documenting the patient’s progress and striving to prevent unnecessary hospital readmissions. Understanding how best to meet the needs of CHF patients and help achieve optimum patient outcomes while containing costs is important for all
case managers.
The Intricacies of Patients with CHF
Heart failure disease management is a primary aspect of the case manager’s role. This encompasses elements of lifestyle changes, awareness of symptoms and what they mean, and the importance of strict adherence to one’s treatment plan. This is, however, a major oversimplification of the case manager’s role when caring for CHF patients.
CHF occurs when the heart is unable to pump well enough to provide oxygen to all of the body’s organs. It can lead to a multi-system failure and death. The most common cause of this condition is a blockage in an artery or multiple arteries that can lead to a heart attack or significant damage to the heart muscle. The risk factors leading to a blockage typically occur over a lifetime and include smoking, elevated cholesterol, hypertension, diabetes, age and family history. Managing patients with CHF involves a complex process reflecting evidence-based guidelines and a patient-tailored approach—essentially a disease management program. For the case manager, the process must be coordinated and comprehensive over the entire continuum of care and healthcare delivery systems. It cannot be restricted to an episode of care or a single setting, which is too often the case following a patient’s admission for acute CHF. A best-in-class case management/disease management approach should be multidisciplinary in order to improve both the quality and cost-effectiveness of the
care provided.
The Impact of CHF
According to Emory Healthcare, nearly five million Americans are living with CHF, with 550,000 new cases diagnosed in the United States each year. In addition, Emory notes:
Nearly 5 million Americans are currently living with CHF.
Almost 1.4 million persons with CHF are under 60 years of age.
More than 5 percent of persons age 60 to 69 have CHF.
CHF’s annual incidence approaches 10 per 1,000 population after 65 years of age.
The incidence of CHF is equally frequent in men and women, and African-Americans are 1.5 times more likely to develop heart failure than Caucasians.
CHF is the first-listed diagnosis in 875,000 hospitalizations, and the most common diagnosis in hospital patients age 65 years and older.
More than half of those who develop CHF die within five years of diagnosis.
As for the cost impacts of this medical condition on our health system, the Institute for Healthcare Improvement (IHI) estimates that almost $30 billion is spent annually on CHF care.
Primary Interventions When Caring for the CHF Patient
While the data relating to CHF patients is distressing, there are well-established and recognized interventions to improve the care patients receive in the hospital and upon discharge, and which are critical to reducing hospitalizations and readmissions. These interventions are part of the IHI’s “5 Million Lives Campaign” and include seven key care components that are also supported by The Joint Commission and the American College of Cardiologists. They are:
Left ventricular systolic (LVS) heart function assessment;
ACE inhibitor or ARB at discharge for CHF patients with chronic/recurrent atrial fibrillation;
Anticoagulant at discharge for CHF patients with chronic/recurrent atrial fibrillation;
Influenza immunization;
Pneumococcal immunization;
Smoking cessation counseling; and
Specific and patient-centered instructions that address all of the following: activity level, diet, discharge medications, follow-up appointments, weight monitoring and what to do if symptoms increase.
Despite these guidelines, one can readily see that the management of patients
with CHF is indeed complex and challenging.
The Case Manager’s Communications with the CHF Patient
Often, when patients are admitted to a hospital with an acute episode of CHF, they are anxious and in considerable distress. The physicians and other clinicians on the team may be quite adept at resolving an acute episode of CHF, stabilizing and preparing patients for discharge. Where the system falls short in many hospitals is in the failure to spend sufficient time conducting an in-depth assessment that would provide a better understanding of what contributed to another CHF-related hospital admission. This is where the case manager is ideally positioned to establish a trusting relationship with patients and their families to uncover valuable information relating to the events and factors contributing to these acute episodes of CHF (e.g., dietary indiscretion, smoking, inconsistent adherence to prescribed medications, financial issues, transportation problems, etc.).
In the initial conversation with patients, it is helpful if the case manager acknowledges that managing a chronic condition such as CHF is not easy for patients or their families, and for this reason, lapses in adherence to prescribed treatment plans and protocols can happen. This assurance allows patients to share what they may have done or failed to do, which may have contributed to the acute episode.
When caring for patients with CHF, case managers must understand that there is a delicate balance of diet, fluid intake and monitoring that can be extremely challenging for patients who likely have had a lifetime lifestyle of risky behaviors. For them, making the necessary changes can be very difficult, frustrating and, often, depressing. Case managers must remind themselves of the enormity of changes the CHF patient must make and convey patience and understanding in instances of lapses in treatment plan adherence.
The timing and frequency of communications between case manager and patients depends on many factors. For instance: Is the patient elderly? Does the patient have a hearing or vision problem? Is there family support? Are there language or cultural barriers? Does the patient have easy access to transportation for doctor appointments? What is the home situation like? Depending on the answers, a CHF patient may be more or less at risk. By maintaining the proper frequency of communications and in-person visits to the home, if needed and based on each patient’s individual circumstances, the case manager can provide the highest level of monitoring and care.
Preparing the Patient (and Family) for Discharge
From the time CHF patients are admitted to the hospital, the case manager needs to be planning for their discharge. This is because the length of stays often are just a few days and many things must be done to create an effective plan and share information with the patient and family as soon as possible. The earlier this communication begins, the more time patients and family members will have to read and absorb the information and ask questions. While many hospitals today have treatment and protocols in place for CHF, patients with this condition also may have one or more co-morbid conditions that necessitate the development of a customized plan for discharge and at-home follow-up.
Once patients are home, it is extremely important that there be a “roadmap” for them to follow. Those patients who lack the basic information about their CHF diagnosis, medications, and the resources and support to manage their condition are at the greatest risk for readmission and/or emergency department visits. Simply providing patients with brochures and information without knowing if their content is understood is very shortsighted. Additionally, patients who cannot afford their medications, do not have the means to buy or access healthy foods or do not possess the literacy skills to monitor and manage on their own are at a much higher risk for readmission and increasingly more costly complications. It is vital for case managers to closely, carefully and consistently monitor multiple factors on behalf of their patients to allow for timely adjustments in their care plans as needed. Doing so will prevent a deterioration of their condition, which can happen in days, in the absence of this ongoing monitoring.
To be monitored as part of the CHF patient’s care plan are certain basics such as:
Taking medications as prescribed;
Eating a low-salt, heart-healthy diet;
Monitoring fluid intake;
Getting regular daily exercise;
Quitting smoking or the use of any type of tobacco;
Avoiding alcohol;
Maintaining a healthy weight;
Keeping a daily record of weight and symptoms; and
Managing stress.
If patients and their families understand these basic guidelines and are able to manage their condition, CHF patients can have an active and enjoyable life. They do, however, need to be mindful of even the smallest changes in their condition, which, left unattended, can result in major setbacks. Two groups of symptoms can happen with CHF—one resulting from fluid build-up and the other when the body is not getting as much oxygen-rich blood as it needs. Case managers need to be very specific with instruction about which symptoms patients and their families must report promptly. They are:
Symptoms reflecting fluid accumulation:
Dyspnea (i.e., waking up in the middle of the night with difficulty catching your breath;
Edema of ankles, legs or abdomen;
Coughing or wheezing; and
Increase in weight – weight gain of three pounds in a day or five pounds or more in one week.
Symptoms indicating a decrease in oxygen-rich blood:
Rapid heartbeat, even with minimal activity;
Vertigo;
Fatigue or noticeable decrease in energy; and
Anorexia.
When CHF patients have other conditions (e.g., diabetes, kidney disease, hypertension, elevated cholesterol, etc.), case managers also need to incorporate evidence-based guidelines for those conditions as part of the care plan. Also important will be to provide referrals to appropriate specialists (e.g., endocrinologists, nephrologists, nutritionists for dietary management, pharmacist for consult regarding multiple medications and potential interactions, etc.), lab tests to monitor multiple conditions and, as approved by the patient’s physician, a possible referral for cardiac rehabilitation. Ideally, the case manager should remain involved or provide transition support to patients moving on to their next setting (e.g., home care, physician’s office, ambulatory clinic, etc.) for the continued coordination and monitoring of the patient’s condition.
Troubleshooting the Trouble Spots
It is not uncommon for case managers to encounter CHF patients dealing with financial barriers to obtaining medication, the inability to keep their doctor appointments, as well as poor communications and literacy issues contributing to their lack of adherence to their treatment plans. Other problems that case managers need to be aware of are those relating to behavioral issues, lack of community resources and support, and the failure to assess and address social determinants of health. If case managers are mindful of the essential activities and core components as defined by our standards of practice, they should be able to identify and then resolve those trouble spots.
Complex Care Management Models of Care
Finally, for CHF patients, care managers will need to understand the different complex care management (CCM) models that may be applied. All of these models focus on areas that extend beyond the patient’s medical issues to include psychosocial issues that affect a patient’s recovery. They reflect a concerted effort to work closely with patients and their caregivers while maintaining liaison with their primary care physician and other providers of behavioral and social services. Additionally, these CCM models are customized to a patient’s location (i.e., rural areas with fewer community resources vs. highly populated metro areas with many large practices and extensive resources). CCM models rely on different operational controls ranging from payer-operated and practice-operated to delivery-system operated and independent regional care management organizations. Each has its advantages and disadvantages, of which case managers should become familiar. For example, while CCM models that rely on a payer-operated approach offer greater flexibility and access to financial resources, they are also prone to greater challenges engaging both patients and providers. CCM models using a practice-operated approach offer greater opportunity for primary care integration, but also often pull case managers away from their care management tasks to cover day-to-day clinic duties.
As you can see, case managers caring for CHF patients will be challenged on various levels; however, caring for these complex patients can also be one of the most rewarding experiences a case manager can have.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates, LLC (www.mullahyassociates.com, Huntington, New York), a leading provider of case management training, certification workshops, online case management training and educational tools. Mullahy is a widely recognized case management pioneer who has held leadership roles in the development of professional standards and certification for case managers, while driving greater awareness of the important role case management plays in improving patient outcomes, processes and cost efficiencies. She is the author of The Case Manager’s Handbook, Sixth Edition, the authoritative case management reference book relied upon as the foundational text for nursing schools across the world by healthcare providers, managed care organizations, insurers, plan sponsors and government agencies.
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