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The Power of a Telephone
Health Data Management Magazine, July 1, 2008
Sometimes picking up the phone can make a world of difference. In two pilot projects, congestive heart failure patients who make daily phone calls to an automated service are entering the hospital far less often than would otherwise be expected.
The patients place a call each weekday, answering a series of questions using the keys on their touch-tone phones. Nurses monitor their responses via a Web site, calling the patients when their answers indicate that they may need some guidance or treatment to avoid getting sicker.
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The Medicaid program in Iowa is in the second year of its project using technology from Pharos Innovations LLC, Northfield, Ill. The project has been so successful that the program is continuing the use of the technology using its own funding now that an initial grant has been spent.
Meanwhile, Billings (Mont.) Clinic is in its third year of a test project that could ultimately result in extra reimbursement from Medicare for keeping patients out of the hospital.
“By catching new symptoms on day one, a nurse is able to intervene in a telephone triage manner,” says F. Douglas Carr, M.D., medical director, education and systems initiatives, at Billings Clinic. “If there’s a delay of several days, the patient will wind up in the emergency room.”
Measurable Results
In the Medicare pilot at Billings Clinic, the hospitalization rate for participating patients was at least 40% lower than the typical rate for heart failure patients, Carr says. As a result, he estimates the savings to Medicare at more than $1.7 million per year. A similar project is ongoing at Park Nicollett Health Services in St. Louis Park, Minn.
During the one-year period ending October 2007, the number of inpatient admissions for 187 participants in the Iowa Medicaid test program was 43% lower than for a control group of similar patients not participating, organizers say. Total charges for all health care services utilization during the period were $13 million less for participants than for the control group.
These projects are simply automating the longstanding, effective practice of frequent interaction with chronically ill patients, says Carol Stone, R.N., a regional manager at Beacon Partners, a Weymouth, Mass.-based consulting firm. “With congestive heart failure patients, changes can occur quickly, so if you can get daily reports you can see trends,” she says.
For example, if a heart patient gains weight suddenly, a clinician can adjust their medication to control water retention, avoiding potentially serious complications, Stone notes. “It’s the trending of the data that’s most important.”
It’s unrealistic to expect seriously ill heart patients to monitor their symptoms on their own and then take the initiative of calling in when they see a potential problem, she adds. “It’s much better to have the patient answer six questions each day and let someone else make the analysis.”
Cardiac patients participating in both programs make a daily phone call to answer a series of simple questions:
* Have you noticed more swelling in the last day?
* Did you wake up short of breath last night?
* Did you sleep in a chair or prop up with pillows more than usual last night?
* Have you had any lightheadedness or dizziness in the last day?
* Please enter this morning’s weight.
* Have you felt more short of breath in the last day?
Nurses review the answers on the Pharos Web site to determine whether to follow up with the patient. Then they document their actions on the Web site.
At Billings Clinic, they also enter the information within the progress notes section of a clinical information system from Cerner Corp., Kansas City, Mo.
Since launching the project in January 2006, Billings Clinic has served about 500 heart failure patients using the telephone-based technology, Carr says.
Medicare’s review of the performance under the first year of the Physician Group Practice Demonstration project did not result in the organization receiving a bonus payment from the government payer. Billings Clinic, which includes a 270-bed hospital plus 10 clinic sites, is hopeful that it will earn an extra payment for year two of the program when Medicare’s review is complete this summer.
The Medicare demonstration, mandated by Congress, is designed to test a hybrid payment method for physician groups that combines Medicare fee-for-service payments with the new incentive payments that encourage preventive medicine. Ten group practices are participating in the program, using various methods with a goal toward minimizing hospitalization of chronically ill patients. Medicare passes on a share of its savings for those programs that hit certain savings targets.
“In the long term, we hope to influence Medicare to change how it pays for the treatment of the chronically ill,” Carr says, pointing to the need to reward payers for preventive medicine. The current fee-for-service system, he contends, rewards providers for repeated hospitalizations rather than for keeping patients healthy.
“Our hope is that we might be able to influence Medicare in a policy debate about creating a set management fee for certain chronic conditions,” Carr adds.
Expanded Effort
The Iowa Medicaid program is considering expanding its use of the Pharos software to patients with other chronic conditions as a result of its initial experience with several hundred congestive heart failure patients, says Thomas Kline, D.O., medical director.
The program is now funding the effort on its own after launching it with an initial $295,000 grant from the Office for the Advancement of Telehealth, a unit of the Health Resources and Services Administration within the U.S. Department of Health and Human Services, says William Appelgate, vice president for planning and technology at Des Moines University, who coordinated the effort.
The grant was obtained through the Iowa Chronic Care Consortium. The consortium, which focuses on care management for chronic diseases, includes representatives of health care providers, major employers, unions, academics and others, Appelgate says.
Iowa Medicaid’s Kline was surprised by the success of the initial project because of the difficulty sometimes experienced when trying to reach low-income Medicaid patients, many of whom have spotty phone service. Previous efforts to reach out to asthma patients with phone calls from nurses were unsuccessful, he notes.
“Congestive heart failure patients are generally in need of help and they were more interested in participating,” he says.
More payers should consider taking a lead role in initiating preventive medicine services, especially those involving daily interactions with the chronically ill, contends Stone, the consultant.
“Payers are interested in doing anything that will decrease their hospitalization rates,” she notes. But prevention efforts must be properly designed, keeping it simple for patients to participate, as in the projects using Pharos technology, she adds.
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