Congestive Heart Failure Disease Management Program

1. Congestive Heart FailureDisease Management Program

2. Project Goals • Coordinate and strengthen healthcare services for patients with chronic disease, in particular, Congestive Heart Failure • Provide clinical preventative services that are proven effective in managing chronic disease • Utilize Patient Navigator services to support coordination of care with hospitals, physicians and clinics that provide treatment and primary care

3. Primary Activities • Implement a CHF disease management program utilizing the CareEnhance Call Center software and utilizing the CHF module of CECC • Coordinate services and activities that are complementary across hospitals, physician offices and clinics • Use telephonic outreach to promote patient self management • Target Service Areas: Harris County and Fort Bend County

4. Eligibility • Patients must: • Be 18 years of age or older • Reside in Harris or Fort Bend County • Have a confirmed diagnosis of CHF • Be uninsured, underinsured or • Be a recipient of Medicaid or • Be a recipient of Medicare and not currently enrolled in a Medicare Demonstration Project • Agree to a primary health home for ongoing CHF management

5. Referrals • Referrals come from any hospital within Memorial Hermann • Initial pilot at Memorial Hermann Southwest • Referrals may be submitted by an clinical staff member or primary care provider • Referrals need to include pertinent clinical information related to the specific needs of the patient

6. Program Scope • The program will not provide any direct treatment • Patients will be introduced, whenever possible, to the program while the patient is still in the acute care setting • Program participation is voluntary • Interventions will be handled telephonically • There may be limited occasions where a home visit is warranted and this is done at the discretion of the RN case manager • Program will utilize both patient navigators and case managers

7. Program Scope • All patients will have an assessment completed by an RN case manager • Based on the assessment, patients will be risk stratified • Patients stratified into the high categories will continue to receive contacts from RNs • Patients stratified into the lower risk categories may be referred to patient navigator for follow up

8. Implementation • First three patients accepted October 17, 2006 • Currently 128 patients enrolled • Response and compliance is improving

9. Program Results

10. Anecdotals • Patient enrolled in Jan, 2008. Since enrollment patient has taken a very proactive approach to health. Patient and spouse are both following low sodium diet, weighing daily, monitoring blood pressure and recording results daily. Patient mails the CM a copy of the log, and takes this information to regularly scheduled physician office visits. No hospital readmission since January. The patient was visiting the hospital once every 4-6 weeks prior to program enrollment

11. Anecdotal • Patient enrolled in September, 2007. Patient had been a smoker for 50 years. Since program enrollment, the patient has stopped smoking, both patient and spouse are adhering to a low sodium diet. Patient is monitoring weight and BP daily and is compliant with medication administration. Patient has not been re-hospitalized since September, 2007

12. Anecdotal • Patient enrolled in September, 2007. Patient’s CHF was consistently exacerbated because the patient is also diabetic. During the initial conversation with the CM, patient stated the glucose was not being checked because the patient could not afford the diabetic supplies. CM worked with the patient to coordinate services through a Medicare provider. The patient had been unaware that supplies would be paid for by Medicare. Patient is now checking blood sugars 4 times daily, checking blood pressure as required, and following a low sodium diet. The patient has increased physical activity and is happy to report the increase in activity level, as the patient is “feeling better”. No re-hospitalizations since September, 2007.