Congestive Heart Failure Disease Management Program

Some days Mildred and her husband, John, cast into a lake near their Clearwater home and catch brim, trout, and catfish. Other days they only catch fresh air. Regardless, the couple says "It's good to be outside and active."

The previous year, this wasn't the case. An irregular heartbeat caused by years of hypertension had left Mildred with a weakened heart muscle. Her physicians recommended that she join Blue Cross Blue Shields of Florida's (BCBSF) Congestive Heart Failure (CHF) Program. Before she could begin the program, crisis struck. An abnormal heartbeat sent her into cardiac arrest. Before she was revived and stabilized, Mildred stopped breathing three times. After transferring to a hospital near her home, she suffered another arrest. Help came in the form of a defibrillator implant from her cardiologist. It worked. In the fall, Mildred's pulse dropped and she was poised to have another cardiac arrest, but the defibrillator shocked her heart back to proper rhythm. She's never gone back to the hospital.

Mildred sites more than her hardware for the remarkable recovery, pointing to her R.N. CHF Care Manager, Mary. After her surgery, Mary visited with Mildred in her home and spoke with her by phone every other week. Mary worked with Mildred's physicians to set up outpatient rehabilitation and help solve unexpected problems like the time Mildred's defibrillator shocked her in the bathtub. Mary also helped Mildred organize her pill regimen and encouraged her to read food labels to control sodium and fat intake. She taught Mildred about the warning signs of congestive heart failure _ swelling in the hands and feet, shortness of breath, fatigue, and chest pain. Now Mildred knows when she should call her physicians. Thanks to her physicians and BCBSF's Congestive Heart Failure Program, Mildred is enjoying a better quality of life.

Program Description

Blue Cross and Blue Shield of Florida implemented a one-year Congestive Heart Failure (CHF) Pilot Program in the Tampa Bay area from February 3, 1997 through February 2, 1998. The purpose of the CHF Program Pilot ("Pilot") was to demonstrate that through participation in the Pilot, plan members diagnosed with CHF, would exhibit improved clinical and financial outcomes. The Pilot objectives were:

In addition to evaluating the clinical and financial impacts of the Pilot, the perception of member and provider participants regarding the value of the program, how effectively it met the stated program objectives and goals, and their satisfaction with the Pilot were evaluated.

A longitudinal outcomes study approach was used to evaluate the Pilot. The findings for the program participants and providers were compared to the pre-enrollment period for all of the evaluation measures except Satisfaction and Compliance. The pre-enrollment period was February 1996 through January 1997. The post-enrollment period was February 1997 through January 1998.

The CHF pilot program was designed by a multidisci-plinary team with expertise in both medical and quality management, healthcare analysis, and process development. The interventions for program participants varied depending on the severity of their CHF and their individual needs.

All participants received an initial phone call introducing the program and an orientation package that included an educational booklet on living with CHF. All participants received an initial needs and status assessment conducted in the home for participants in the medium and high intervention level categories and by phone for participants in the low intervention level categories. The participants in the medium and high intervention level categories received phone monitoring from daily to multiple times per month depending on the severity of their illness and need of the participant. Scales for weight monitoring were provided as needed. Coordination of care with physicians, other providers (such as home health agencies), and community resources (including support groups and Meals on Wheels) was provided as needed. Re-assessments (in the participant's home for those high and medium intervention level categories and by phone for those in low intervention level categories) were performed at specific intervals and for participants who experienced a significant change in their health status or a hospitalization.

Physicians were educated on the guidelines for heart failure that were developed and published by the Agency for Health Care Policy and Research (AHCPR). They were also educated on components of the program including the value of ejection fraction measurement in diagnostic testing, the appropriate use of ACE inhibitors (increased use, where appropriate) and calcium channel blockers (decreased use, where appropriate), and measurement of the New York Heart Association (NYHA) classification. Participants and providers were educated on the appropriate use of self-management plans to facilitate the participant's care.

Population

Of the 249 members enrolled in the Pilot, 186 met the criteria for inclusion in the Pilot study. Ninety percent of the study group was over 60 years old and 56% were women. Eight of the participants expired prior to the end of the Pilot. The study inclusion criteria were as follows:

The population included members from all levels of severity as opposed to a focus only on the most severe cases. The population was segmented into groups based on their individual CHF functional status, support systems, and educational needs. This segmentation approach classified them into high, medium, and low intervention groups according to the level of their intervention requirements. The distribution of the study population into the high, medium and low intervention groups was 19%, 32%, and 49%, respectively. All three intervention groups had more than 30 participants; thus the size of the study group and each intervention group was sufficient to show valid results.

Evaluation And Results

The Pilot included an evaluation of process and outcome criteria in the following 5 areas:

The findings were compared against specific goals which related to each of the Pilot objectives. The data to measure program results was collected by the RN care managers through a combination of chart reviews and interactions with the program participants and their physicians or the physician's office staff. Satisfaction surveys were conducted with program participants, physicians and office staff by an independent contractor. To evaluate the Pilot, a longitudinal outcomes study approach was utilized. The findings for the program participants and providers were compared to the pre-enrollment (or baseline period) for all of the evaluation measures except for satisfaction and compliance. Satisfaction and compliance measures were not evaluated during the pre-enrollment (or baseline) period. The pre-enrollment period was February 1996 through January 1997. The post-enrollment period was February 1997 through January 1998.

Table 1 depicts the evaluation measures used for each goal, the analysis results, and the associated statistical significance. All of the tests for statistical significance were conducted at the 95% significance level.

Analysis Overview

Our analysis showed that the CHF Pilot met the study hypothesis. The Pilot participants exhibited improvement in both clinical and financial outcomes. Also, the Pilot participants experienced statistically significant improvement in their perceived quality of life (64% experienced a decrease in their LHFQ scores) and improved functional status (19% experienced a decrease in their NYHA class). They experienced a statistically significant decrease in frequency of CHF inpatient admissions (29% reduction), CHF inpatient days (39% reduction), CHF related medical costs (58% reduction), and overall medical costs (39% reduction). In addition, the participant compliance with their medication regimen, diet, and weight monitoring was extremely high immediately following enrollment and then stabilized at a high level.

The CHF Pilot did not prove the hypothesis that through participation in the CHF program physicians would improve the diagnosis and treatment of CHF. There was no significant increase in the use of ejection fraction measurement to confirm the diagnosis of CHF. Also, there was no significant change in the appropriate use of ACE inhibitors and calcium channel blockers The expected increase in the use of ACE inhibitors and decrease in the use of calcium channel blockers was based on information shared with physicians that "patients with heart failure due to left-ventricular systolic dysfunction should be given ACE inhibitors unless contraindications exist".¹ Additionally, physicians were educated about various studies which showed that ACE inhibitor agents differ very little in efficacy and safety, and that all ACE inhibitors are equally effective in reducing hospitalizations and enhancing overall functionality.²

In addition to evaluating the clinical and financial impacts of the Pilot, an independent contractor evaluated participants for their satisfaction with the program and their perceived value of the program. A statistically significant majority of the member participants (89%) showed a high level of satisfaction with the Pilot and 90% perceived the program as providing a high level of value.

A statistically significant majority of providers (64%) indicated a high level of satisfaction with the program; however, only 34% of providers perceived the pilot as highly valuable and 34% felt the program met its objectives. In conducting the survey, many providers chose not to participate in the survey or only answered the general/overall satisfaction question. The vast majority of providers only had one or two participants in the BCBSF CHF Pilot program; therefore, the providers did not interact with the RN care managers on a frequent or routine basis. Also, the physicians and their staff reported that several managed care plans had recently implemented special programs for their patients with CHF. Many providers reported satisfaction with all of these programs but found it difficult to answer the more specific evaluation questions for the BCBSF CHF Pilot program. For these reasons, there was a low participation rate for the provider survey and a very low number of responses for specific questions in the survey. The resulting low number of responses for the specific questions about the value of the program and the program objectives made for a lower confidence level in the overall results obtained for those survey questions.

One unexpected benefit of the program was the statistically significant clinical and financial impacts on the cases with the lowest severity of CHF. Little impact for these members had been anticipated because the participants in the low intervention level were monitored much less frequently and were provided a lower level of interventions.

Comparison Group

To further validate the results demonstrated by the Pilot, an attempt was made to identify a comparison group of plan members with CHF who were not offered the interventions used in the Pilot. The Southern area of the state had begun identifying candidates for enrollment into a similar CHF disease management program. For 192 of these members, the diagnosis of CHF had already been confirmed with the member's physician and claims data was available for the appropriate time periods required to qualify for study in this comparison group. Since the pilot began on February 3, 1997, all of this comparison group's claims for a year prior to that date (year 1) were used as the baseline or pre-enrollment period and all the claims for a year after that date (year 2) were used as the post-enrollment period. The comparison group started with 214 candidates. Fifteen candidates were eliminated who did not have claims prior to February 3, 1997 and seven were eliminated who had gaps in their enrollment period. Table 2 compares the key financial and utilization indicators for the two groups.

Table 2. Comparison of Key Financial and Utilization Indicators
Key Quality Indicator	CHF Pilot Participants	Comparison Group
CHF Admissions (1000) PMPY.	29% reduction from baseline.	69% increase from year 1 to year 2.
CHF Inpatient Days (1000) PMPY.	39% decrease from baseline.	83% increase from year 1 to year 2.
CHF Emergency Visits (1000) PMPY.	18% decrease from baseline.	134% increase from year 1 to year 2.
Total Costs PMPM.	39% decrease from baseline.	2% decrease from year 1 to year 2.
CHF Total Costs PMPM.	58% decrease from baseline.	51% increase from year 1 to year 2.

As you can see from this comparison group when assessing one year to the next, the comparison group members did not experience the same degree of decrease in their utilization and costs as the CHF Pilot participants. In fact, for 4 out of 5 of the measures the comparison group actually experienced increases in utilization or costs. This further validates the impact of the interventions on the study group.

Summary

In summary, the CHF Pilot achieved the objectives in 4 out of 5 categories and proved that a comprehensive disease management program such as the CHF Pilot can:

Our analysis identified the opportunity to simplify and speed up the administrative process used to validate the member's condition, obtain the physician approval, and complete the member's enrollment into the program. Also, an opportunity exists to further enhance physician involvement, cooperation and feedback, and to explore program design modifications focused on CHF diagnosis and treatment. At the end of the Pilot, the CHF program was continued as an operational program and has now been expanded to other areas of the state.

Congestive Heart Failure Disease Management Program

Beverly Russell, RN, MBA and Deborah Chambers, MS
Beverly Russell, RN, MBA and Deborah Chambers, MS are with Blue Cross Blue Shield of Florida.

Introduction

Program Description

Population

Evaluation And Results

Analysis Overview

Comparison Group

Summary

Jacksonville Medicine / September, 1999

Congestive Heart Failure Disease Management Program

Beverly Russell, RN, MBA and Deborah Chambers, MS Beverly Russell, RN, MBA and Deborah Chambers, MS are with Blue Cross Blue Shield of Florida.

Introduction

Program Description

Population

Evaluation And Results

Analysis Overview

Comparison Group

Summary

Jacksonville Medicine / September, 1999

Beverly Russell, RN, MBA and Deborah Chambers, MS
Beverly Russell, RN, MBA and Deborah Chambers, MS are with Blue Cross Blue Shield of Florida.