Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 1. Cardiac Care


Keystone East, HMO Oregon, and Aspen have programs for congestive heart failure (CHF). At Keystone East, practice guidelines have been developed for its management. In addition, each CHF patient undergoes an assessment that includes obtaining information on the family or other support systems and on problems the patient might have in accessing community-based resources. Also, specialized nurses, employed by a home health agency, perform home assessments, and patients undergo educational training on such topics as nutrition and the need to monitor weight and take medication as prescribed. Patients also receive printed materials--for example, on fluid intake, weight, and medication issues. Several home visits by nurses are typical, with the enrollee being monitored thereafter by telephone. The CHF program was reported to have reduced inpatient admissions by 50 percent. Most of the patients in the program have significant comorbidities, which the staff has been trained to address.

The program at HMO Oregon emphasizes the use of ACE inhibitors for treating CHF. Primary care physicians are sent lists of members based on analyses of claims indicating the presence of CHF and asking whether the patients are on ACE inhibitors. The guidelines for treatment of CHF issued by the Agency for Health Care Policy and Research are also distributed. Finally, nurse care managers call CHF patients to discuss weight and other health issues. The frequency of the calls can vary from weekly (typical for patients when they first enter the program ) to once every few weeks.

Kaiser Colorado has a program for patients admitted to the hospital with ischemic heart events. It includes both one-on-one counseling and group classes that focus on cholesterol levels, beta blocker therapy, aspirin therapy, smoking cessation, exercise, and diet. Also, Kaiser Colorado initiated a Clinical Pharmacy Anticoagulation Service several years ago to decrease the morbidity associated with anticoagulation, principally with heparin and coumadin. The most frequent conditions requiring these agents are atrial fibrillation, deep venous thrombosis, and valvular heart disease. The service has a caseload of about 3,700 patients. Staffed by seven pharmacists (three PharmD’s and four with BS degrees) and two technicians, it assumes responsibility for dosing, monitoring, and redosing patients who receive anticoagulants. One of the seven pharmacists takes calls 24 hours a day, on a rotating basis, by carrying a cell phone and laptop, thus allowing providers to contact the service at any time to obtain a consult regarding the patient’s therapy. To reduce the need for inpatient care, the service collaborates with the local visiting nurses association to arrange for home monitoring of patients with deep vein thrombosis who are being treated with low molecular weight heparin as outpatients.

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