Case management of Patients with CHF

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Case management of Patients with CHF

• Presenter
• Claire Prentice
• Clinical Nurse Coordinator
• Surrey Memorial Hospital

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Case Management

• Definition developed by CMSA
• a collaborative process which assesses, plans,
  implements, coordinates, monitors and evaluates
  options services to meet an individuals health
  needs through communication and available
  resources to promote quality, cost-effective
  outcomes
• ( Huber, D Ph.D, RN, FANN, CNAA The Divesity
  of Case Management Models Lippincott Nov./Dec.
  2002 )

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• Case Management
• Is experiencing rapid growth and evolutionary
  transition.
• There are a diversity and richness of case
  management models found in practice.
• generally manages risk and coordinates care as
  core functions, what is actually done beyond this
  is highly variable
• Is both disciplinary and interdisciplinary. No
  discipline owns it multiple disciplines are
  involved.

4

• Many types of models with many labels presented
  in the literature.
• Social
• Primary care
• Medical/social
• Independent
• Insurance
• Direct care model gap/filling model
• 3 types of CM in Nursing
• Hospital based
• Hospital community
• Community - based

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• Nursing and healthcare models tend to focus on
  the management of the health/illness, disease, or
  rehabilitation needs of an individual or
  population.
• The use of CMPs has successfully
• Contained health care costs
• Reduced LOS
• Improved quality of care
• Streamlined use of resources
• Opened communication lines among healthcare team
  members

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Surrey Memorial Hospital Heart Function Clinic

• In operation since 1996
• Nurse managed cardiologist directed
• Serves heart failure clients in the North and
  Central Surrey Region
• Operates once weekly for 4 hours
• Nurse available Mon Fri and after hours for
  crisis management, telephone follow-up
• New patient referrals vary from year to year
• 98- 103 99 85 2000 71 01- 61 02
  19
• Repeat visits
• 98 456 99 443 2000 320 01 311 02-
  214

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Nurses Role in the HFC

• Promote and monitor health, alter tx PRN
• Provide emotional support to clients and family
• Education on nutrition, medications and activity
• Telephone follow- up and crisis management on a
  need basis.
• Facilitate end of life care

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• PROGRAM OBJECTIVES
• Improve QOL for patients family
• Reduce LOS and ER/hospital admiss.
• Promote patient self management of their chronic
  disease process
• Provide education for the caregiver/ family about
  the care of patients with HF
• Create a linkage with Palliative Care
• Establish a centre for coordination of clinical
  trials for HF
• Establish accurate data collection

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Case management Processes

• Patient Selection Process
• Physician referral required -GP/Cardiologist
• 2 pathways of referral education vs education
  and medical management
• Documented evidence of HF required
• - Echo, MIBI, MUGAs ECG, Cath
• recent labs and BNP ( if available )
• Recent admission to hospital with HF
• NYHA Class I-IV

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Communication Process with Physician
Notification of 1st visit date with explanation
of purpose of clinic Consult from Clinic
Cardiologist on 1st visit Summary of changes
done at each visit sent to GP labs, clinical
findings, referrals to other disciplines and
specialists, issues
for them to follow-up on. Discharge
notification sent along with latest medication
record.
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Documentation and Monitoring Tools Patient
summary form Admission
Assessment Physician flow sheet
Education documentation sheet Patient care flow
sheet Lab flow sheet Telephone contact
sheet SMH Physicians order form
Medication flow sheet Medication
history record. Patient brochure Medication
record wallet card Low salt guide info Medication
information sheet CHF Booklet- Living with
Congestive Heart Failure Personal Action Plan
form
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Patient Education Process NYHA Class I-II
education only - of visits dependent on patient
level of understanding NYHA Class II-IV
education and medical management patient is
seen on a regular basis ( q weekly ) if necessary
for close medical follow-up and education.
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Patient Education Process ( contd ) Education
Focus each visit on the following etiology of
heart failure, recognizing signs and
symptoms of worsening HF importance of daily
weight and fluid balance. low Na diet,
exercise, energy conserving mechanisms
medication compliance. Self management goals
are initiated documented on PAP
reinforcement of patient specific education
needs done on each visit
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Protocols or Standing Orders Canadian Guidelines
for the Management of Congestive Heart Failure
Beta blocker titration goals Diuretic
titration goals Referrals to other disciplines
Ie, dietician, social worker, physio, OT, Home
Care Nursing for follow up, assessment for
placement as required. IV Lasix infusion in
Ambulatory Day Care. IV Lasix infusions in the
community
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• Protocols and Standing Orders ( contd )
• BNP level drawn on admission, discharge and in
  the decompensated patient.
• Discharge criteria as a standing order
• Improvement at least 1 functional class
• Patient clinically stable as evidenced by stable
  weight, and no overt findings of HF in the last 2
  visits.
• Patient has met his education outcomes
• Patient is on all proven therapy with maximal
  tolerated dose obtained.

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Responsibilities of the Case Manager.

• Refer pts. to the clinic from the hospital or
  community with agreement of cardiologist.
• Demonstrates and performs advanced physical
  assessment skills along with providing emotional
  and spiritual support to patient and family
  members.
• Provides education on heart failure management
  and reinforces with the patient on an ongoing
  basis.

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Responsibilities Contd

• Facilitates development of patient self
  management goals
• Follow up on patients between visits on
  clinical status, medication titration, lab and
  diagnostic test results and to provide crisis
  management for de-compensated patients.
• Assesses and facilitates referrals for other
  health disciplines
• dietician, social worker, OT, physio in hospital
  
  
  community, chaplain, palliative care, home care
  support.

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Responsibilities contd

• Acts as a clinical role model and resource for
  other nurses and disciplines.
• Assists in the ongoing maintaining and
  evaluation of the program with implementation of
  Quality improvements as required.

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What are the key elements for successful case
management?

• A good working relationship between clinic nurse
  physician.
• Strong knowledge base of disease process
• Excellent assessment skills.
• Strong patient advocate
• Being a good listener
• Aware of hospital and community resources
• Facilitation of patient education and constant
  evaluation and reinforcement.
• Promotion of patient self management.
• Sense of humour / sensitive to cultural
  differences

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3 most important things I learned about
implementing CM

• Good communication skills are crucial both verbal
  and non verbal.
• Maintaining a positive and caring environment for
  clients
• The promotion, facilitation and support of
  patient self management skills.
• Looking at the patient as a whole being and
  facilitating their emotional, spiritual and
  physical well being
• Good working relationships and knowledge of
  duties of other disciplines.

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What barriers to case management have you
experienced?

• Limited resources and or time for consistent
  follow-up of patients in the clinic setting
• Limited resources in the community ( ie home care
  nursing ) to better assist patient independence
  and compliance of treatment or to assist family
  with patient care when condition worsens.
• Lack of primary care physician involvement as a
  team member in the patients care.
• Lack of data base to track outcomes and/or
  resources to facilitate obtaining this
  information

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END
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Mid Main Community Health Centre

• Multi-Disciplinary Clinic established in 1988
• (medical, dental, nurse clinician, clinical
  pharmacist,
• part-time pediatrician)
• Located on the east side of Vancouver
• Highly diverse patient population

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Primary Case ManagerDiane Middagh

• Multi-Disciplinary, team oriented, primary care
  clinic
• Case management based on working within a team
  setting
• Establishing CHF registry
• Routine audits of registry and charts
• Creation of menu of intervention for physicians
  utilizing CHF guidelines
• Initiation of planned visits

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Case management of Patients with CHF

• Weekly meetings with members of the primary care
  team
• Planned visits within the clinic or in patients
  own home
• Patient education regarding CHF, salt intake,
  fluid restriction
• Baseline education for everyone in the registry

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Objectives

• Education regarding the term CHF
• Lifestyle discussions
• salt, fluid, activity, smoking
• Self-management goals
• Daily weights
• Salt and fluid intake
• When to phone clinic (palpitation, fluid
  overload, SOB)
• Medication titration

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Case Management Processes

• Nurse and pharmacist takes F/U lead
• Planned visits
• Initially as often as required, then bi-weekly x
  2, then monthly, then quarterly
• Protocols or standing orders
• None implemented as yet, lots of informal
  discussion
• Patient selection process
• All patients in registry require initial planned
  visit
• Communication with physician
• Through the menu of interventions and face to
  face discussions

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Case Management Process (continued)

• Documentation and monitoring tools
• The registry and the patient chart
• Patient education process
• 11 sessions
• Patients pamphlets
• Evaluation Process
• Were not there yet, monthly data reports and
  then discussion

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Tools to support the process

• Flow sheet
• Use of the provincial CHF guidelines
• Educational materials
• Healthy Heart Program patient handouts
• salt and fluid handouts
• Ministry of Health flow sheets
• collaborative flow sheets
• scales
• Supportive team environment
• Weekly primary care team meetings

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Team Environment
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The key to successful case management

• Supportive team
• Buy-in from all members of the team
• Administrative support

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The three pearls of wisdom about implementing
case management

• Supportive team environment
• Office systems
• Successful patient outcomes

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Barriers to case management
Too much work not enough time
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Questions?
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Contact Info
Diane Middagh Primary Care Nurse
Clinician 604-873-3666, extension 248 E-mail
midmaindocs_at_telus.net