Cardiac program cuts hospitalizations by 87%
Cardiac program cuts hospitalizations by 87%
Multifit uses follow-up to gain patient compliance
A home-based system for managing cardiac patients has drastically reduced hospital admissions and emergency department visits in the three years the program has been offered to HMO customers around the country. Multifit, developed by researchers at Stanford University and licensed by Buffalo Grove, IL-based Cardiac Solutions, relies heavily on frequent nursing contact in person and by telephone with patients in 30 states who have heart failure or cardiovascular disease.
For most of those patients, it works in a big way. One study on Multifit, published in January in American Journal of Cardiology, showed the program reduced hospitalization rates by 87%, emergency department visits by 67%, and cardiology visits by 31% among 51 heart failure patients who had been hospitalized at a northern California Kaiser Permanente medical center. The patients, who participated in Multifit for nearly a year and were followed for about another six months, also reported significant improvements in functional status, symptoms, and dietary sodium intake. Another study done last year on 902 patients in 10 of HMO-operator Humana Inc.’s markets found that Multifit reduced hospitalization rates by 70% and emergency room visits by 68%.
"We have demonstrated over time our ability to stabilize a normally unstable population," says Gene Miller, executive vice president for Cardiac Solutions. "Multifit reduces patients’ dependence on acute care and keeps them happy."
The cornerstone of Multifit is using experienced certified nurses who are supervised by physicians to work with patients individually and help them manage their symptoms at home, Miller says. After an initial in-home visit, the nurses work with patients mostly by telephone from offices in 11 regional Cardiac Solutions offices. When a situation warrants, the program calls on contracted "nursing partners" in the community to make additional home visits.
Multifit’s protocols are based on national guidelines from the Agency for Health Care Policy and Research and the American Heart Association. These guidelines often fail in clinical practice, Multifit’s developers say, because no one has the specific responsibility of making sure they’re implemented and because of logistical problems including little time for individual patient-physician contact. Multifit seeks to solve such problems through nurse managers who evaluate each patient’s treatment plan and medications to make sure they follow the guidelines.
If guidelines and treatments don’t match, the nurse will point out the differences and ask the physician whether any changes should be made. Besides providing a check and balance system, this approach also offers good decision making by a nurse at a lower cost than using a physician’s time, says Jean Foltin, RN, BSN, vice president of clinical services for Cardiac Solutions. For example, one area the nurses focus on is the use of ACE inhibitors, which sometimes are not prescribed at optimal doses suggested by national guidelines. In the American Journal of Cardiology study, the number of patients who received target doses of one ACE inhibitor, lisinopril, increased by 82%.
Perhaps the most important role of the nurses is patient education and support. "The nurses empower the patients," Foltin says. "They have a long-term relationship because these patients have a chronic illness and we don’t discharge them. It’s hard for many patients to stay on the straight and narrow when you’re asking them to make big changes for the rest of their lives. What we provide is almost like a support group to decrease their potential to stray."
After the initial home visit and case conference with the physician to assess the patient’s situation and needs, the nurse begins regular contact with the patient by telephone. Patients are called weekly and then monthly as their condition improves. The nurses follow a scripted format for the calls, asking a series of questions and entering the responses into a database as they go. They also go over a specific educational topic with the patient each time. If a situation arises that warrants a personal visit, a home health nurse will be dispatched to visit the patient and can perform emergency treatments such as intravenous diuresis if the physician so directs. Home visits also may be done periodically for elderly patients in cases where it is important to see the home environment, the medications they’re taking, and what types of foods they’re buying. Patients may call the nursing center themselves if they need immediate help.
"Many of our nurses were skeptical about the phone contact at first, but they’ve found that educating over the phone has its advantages," Foltin says. "They can divvy up the topics into snippets of information, give the patient an assignment, and follow up next time. The home health nurse has to do a lot at one time. Also, the patient’s total attention is focused on listening to the nurse on the phone, not on distractions like the television, the cat, or the phone ringing."
The results of the phone conversations are reported to the physician and periodically to the patient, along with results of written questionnaires patients complete four times a year. Seeing their progress on paper is a good motivator for patients, Foltin says. If patients know someone is watching their sodium intake, for example, they’re much more likely to watch their diet.
"With home health, when patients improve, they’re discharged, and then they don’t get the reinforcement," Foltin says. "The symptoms begin to creep back after a while. With Multifit, we’re supportive in a proactive way. We’re taking what are known to be the most effective treatment guidelines and doing our best to get them implemented."
[For more information on Multifit, contact Cardiac Solutions, 1615 Barclay Blvd., Buffalo Grove, IL 60089. Telephone: (800) 343-6311.]
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