Henry Ford Health System is focusing specifically on preventing unnecessary hospitalizations among congestive heart failure (CHF) patients. Using a predictive model developed by a private company, Henry Ford ambulatory case managers can identify CHF patients who are most at risk for either a first admission or a readmission within 30 days hospitalization. Because of Henry Ford’s integrated electronic health record (EHR), the predictive model can pinpoint high-risk patients and target the information for inpatient and outpatient use.
High-risk CHF outpatients are being paired with nurse case managers who are part of the care team at Henry Ford’s medical homes. The case managers coach the patients on how to manage their CHF. Patients who consent are also hooked up with telemonitoring capabilities through Henry Ford’s home health agency.
“The technology gives the case managers direct feedback on a patient’s blood pressure, pulse, weight, and even their pulse oximetry,” says Cara Seguin, RN, MSN, director, Center of Clinical Care Design. “We combine these data with the subjective information we get from our patients, such as whether they’ve been more short of breath than usual. All of these insights help the case manager know when to reach out to the patient and prevent their disease from getting unmanageable.”
“We have algorithms that the case managers use when patients gain extra weight or develop other problems,” says Henry Ford’s Richard Dryer, MD, chief medical officer, primary care. “For instance, the algorithm for weight gain tells the case managers to have the patient take more diuretic.”
The case managers even have algorithms that help them determine when a patient is stable enough to graduate from the intensive monitoring program. “We learned this from our first case management experience,” says Dryer. “We didn’t have a way of discharging the patients from the program. They got in and stayed and that didn’t help the patients who needed to be coming into the program.”
In place for the last six years, Henry Ford’s medical homes got a major funding boost from the Michigan Primary Care Transformation Project, which is part of a Centers for Medicare & Medicaid Services (CMS) demonstration project. “The key thing about this particular CMS demo was the upfront money that allowed us to hire additional case managers who would be paid for by the pilot,” says Dryer.
During the first part of 2012, the health system hired an additional 14 outpatient case managers, for a total of 23. However, even the additional staff would not be enough to monitor all Henry Ford patients with chronic conditions. That’s why the health system has adopted a targeted approach to disease management that focuses on transitions of care for the sickest of the sick.
“There are a lot of sick patients in a chronic disease population,” says Seguin. “So you have to sort out who needs what when there are limited resources.”
This is different than Henry Ford’s past approach, says Dryer. “Physicians used to refer patients with chronic diseases to case managers,” says Dryer. “For instance, they asked the case manager to help a diabetes patient lose a little weight. Now, the focus is switched to keep people out of the hospital. So our case managers identify the sick patients and then confer with the physician on whether a patient would be right for the case management program.”
Henry Ford already knows that home telemonitoring can reduce hospitalizations. “The 30-day readmission rate for these patients is about 5 percent in our system’s e-Home Care program,” says Seguin, compared to an average all-cause readmission rate of 13.5 percent across Henry Ford.
Now with its predictive modeling and enhanced case management capabilities, Henry Ford can pinpoint the patients who would most benefit from this telemonitoring. Seguin is currently tracking program costs, including staffing and telemonitoring. “In 2013, we hope to show the costs of our program versus the cost of a hospital admission and identify a true cost savings in reduced, avoidable, primary-care-sensitive ED visits and re-hospitalizations,” she says.
Interviewed for this case study (in order of appearance): Cara Seguin, RN, MSN, director, Center of Clinical Care Design, Henry Ford Health System, Detroit (firstname.lastname@example.org). Richard Dryer, MD, chief medical officer, primary care, Henry Ford Health System (email@example.com).
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