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Heart Failure Support Service Makes a Positive Difference

By Rebecca Ward, RN

The Washington (PA.) Hospital is a 264-bed teaching community hospital serving a five-county area of southwestern Pennsylvania. For case
managers at the Washington Hospital, as for their counterparts nationwide, heart failure patients have always presented a special challenge.
In October 2002, The Washington Hospital implemented a Heart Failure Support Service with the aim of enhancing heart failure patients’
health and quality of life, and reducing the frequency of their hospitalizations. This program has yielded positive, measurable results. In April
2005, the program received two awards: the first ACMA Innovation in Case Management Service Award, presented at the annual conference
in Chicago, and the 2005 Annual Achievement Award, Honoring Excellence and Innovation in Health Care, from the Hospital and Health System
Association of Pennsylvania.

The information published on the website of the Heart Failure manager who had expressed a strong professional and personal
Society of America (www.hfsa.org) provides some sobering statistics. interest in the treatment of heart failure patients. This individual was
The annual national expenditure for patients hospitalized with convinced that these patients could avoid some hospitalizations and
heart failure is expected to exceed $15 billion this year. It is the experience improved quality of life if they were provided with
largest expense for Medicare. The human side of the equation appropriate education, support and self-management skills. One of
is more profound. Nearly 5 million Americans are living with heart the family practice physicians on the hospital’s medical staff served
failure, and 550,000 new cases will be diagnosed this year. Twenty as “physician champion” and provided the program with at least
percent of those diagnosed this year will die within the first year of 25 participants for the
diagnosis. These people live with a pattern of start-up phase.
hospital readmission, Healthcare
social isolation and professionals frequently
depression due to their refer to heart failure
disease process. patients as noncompliant
Medicare will pay for not adhering to their
for a heart failure medication instructions
patient’s acute episode and other directions
of treatment, but it is given by their
possible to break this cycle physicians. However,
of physiologic decline if the assumption that
disease is identified earlier drove the plan
and post-discharge follow- development for the
up provided. (Currently, Heart Failure Support
none of this work would be Service was that this
reimbursed.) The same “noncompliance” is
picture can be painted for often not deliberate
persons with chronic or willful. Instead,
obstructive pulmonary disease it was believed that
or diabetes. Education, lifestyle these patients and
modification, psychosocial their caregivers were lacking essential,
support, and case manager empowering information and were unaware that their lifestyle
follow-up by people in the community who are known to the patient choices could play an important part in arresting progression of
can positively impact this profile. An additional benefit would be lower their disease and preventing unnecessary emergency room visits.
costs related to emergency department visits and hospital repeat It was also recognized that many persons living with chronic disease
admissions for these chronic illnesses. suffer from depression, which can interfere with good self-care if
The Washington Hospital became part of a growing national unrecognized or untreated.
initiative to improve the treatment of heart failure patients with its The Heart Failure Service was implemented in October 2002.
decision in 2002 to develop a Heart Failure Support Service. The idea for Projections were that it would serve about 50 to 75 participants in the
this service originated in joint discussions between the Director of Case first year. However, at the end of the first year, more than 100 individuals
Management and the Director of the Cardiac Center of Excellence. A and their families had benefited from the Heart Failure Case Manager’s
one-year government grant was secured to provide partial funding. interaction and education. With the service now in its fourth year,
The Director of Case Management entrusted responsibility for current enrollment is 261. The Heart Failure Case Manager has access to
development of the Heart Failure Support Service to an RN case a multi-disciplinary team that includes social workers, dietitians,

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Heart Failure Support Service Makes a Positive Difference (continued from page 7)
exercise physiologists, physical therapists, respiratory therapists,
pharmacists, and others. The management team is supportive and
continues with efforts to secure additional grants.
A physician’s referral is required for admission to the Heart Failure
Support Service. The encouragement of the Inpatient Case Manager or
members of the nursing staff often prompt this referral. The patient’s
primary care physician, cardiologist, or any other specialist may refer
program participants. Family medicine physicians have made the
greatest numbers of referrals. The local physician community has been
very supportive of the program.
HOME VISIT A KEY COMPONENT
Once the physician referral is received, the Heart Failure Case
Manager telephones the patient to schedule a home visit. Most
patients are glad to have this opportunity, and the home visit
establishes a personal relationship that is valuable for their ongoing
care. The home visit lasts about an hour and a half. By going to the
patient’s residence, the Heart Failure Case Manager becomes aware of
any factors that may hinder compliance with self-care, and can work
on ways to help the patient overcome these.
At the home visit, patients receive verbal education about heart
failure and self-care, including a lesson in reading food labels for
sodium content. They are taught a “layperson’s version” of the New
York Heart Association classification so they can evaluate changes in
their activity limits and recognize when to contact their physician. A
quality of life survey and a depression screen are administered. Besides
a packet of printed information, participants receive, at no charge, a
medication organizer; a bathroom scale with a large, well-lighted
digital display for daily weight checks; and a “Living with Heart Failure”
video to help them begin their journey of learning to self-manage and
to partner with their physician.
After the home visit, the Heart Failure Case Manager continues the
relationship with follow-up phone calls to assist and support the
patient’s lifestyle changes. Participants are encouraged to call if
assistance is needed. For urgent concerns, they are given a toll-free
number that activates a beeper carried by the Heart Failure Case
Manager. Patients and their caregivers are invited to attend a free six-
part weekly education program at the hospital’s Wilfred R. Cameron
Wellness Center. Cardiologists, nurse practitioners, social workers,
dietitians and pastoral care personnel teach these classes. Participants
and educators alike enjoy the series, coordinated by the Heart Failure
Case Manager. Another benefit offered to patients in the Heart Failure
Support Service is a “scholarship” for a specialized heart failure exercise
program offered through the hospital’s Way to Wellness fitness program.
A monthly support group is conducted for program participants. It
features speakers from the hospital or community presenting topics of
interest, such as end-of-life issues discussed by the hospital’s Hospice
Coordinator or members of Pastoral Care. Another means of
communicating with and encouraging patients is a newsletter published
at least twice annually, featuring articles about quality of life, healthful
recipes, facts about sodium and dates of support group meetings.
The Heart Failure Case Manager maintains a database that
contains confidential, security-protected detailed information about
C A S E M A N A G E M E N T
each program participant’s home situation, items of discussion on
follow-up phone calls, medication changes, and community services to
which the patient has been linked. This database can be accessed by
staff members of other departments in which the patient may receive
care, such as the Diabetes Education Center or Pulmonary Support.
Even though the Heart Failure Support Service operates with a
“staff of one,” many other health professionals contribute to its success.
For example, Social Worker Case Managers are consulted for difficult
socio-economic needs; nurse practitioners participate in education
classes and the support group; and lab managers, hospital
pharmacists, and information systems personnel share their expertise
for the benefit of heart failure patients. Case Management staff
members, as well as physicians, have been unwavering in their support
of the program.
READMISSION RATES DOWN
The Heart Failure Support Service has yielded an impressive
outcome: Since its implementation, the 30-day readmission rate for
heart failure patients at The Washington Hospital has decreased from
24 percent to 9.8 percent. This achievement is testimony to what can be
accomplished with administrative support of innovative ideas. Dollars
saved are more difficult to quantify, but by allowing a greater number of
hospital beds to be filled with paying DRGs, the significant drop in 30-
day readmissions clearly is making a positive financial difference.
When program participants are admitted, the Heart Failure
Case Manager tries to ascertain whether the reason for admission
could have been prevented by earlier intervention. She also offers
information to the hospital staff that may assist the discharge
planning process and help the patient maintain as much
independence as possible. This unique role as an outpatient case
manager with an inpatient office presents many opportunities to
advocate for the participant and to help fill the information gaps
that sometimes exist between acute and outpatient care. It also
provides a unique perspective for processes in the discharge plan
that may need to be improved.
One more positive result of is that depression scores have
decreased and quality of life scores increased for many of the patients
enrolled in the Heart Failure Support Service. This change speaks
volumes about the value of the service to patients, given that this is a
population in which 50 percent do not survive beyond five years of
diagnosis. Simply knowing that a health professional cares about how
well they cope with a very difficult and complex disease can be a
tremendous asset to these patients.
ABOUT THE AUTHOR
Rebecca (Becky) Ward received her nursing diploma from The
Washington (Pa.) School of Nursing. Of her 22 years in health care, the
past 16 have been spent at The Washington Hospital. She became an RN
case manager in 1996, and was named Heart Failure Case Manager in
October 2002. Ms. Ward’s past experience includes cardiac and medical-
surgical staff nursing, long-term care, and home health care. Ms. Ward
received the 2005 ACMA Innovation in Case Management Service Award
sponsored by Landacorp, a SHPS company.