Care of the Heart^sm
Heart Failure (HF) Disease Management Program

The Care of the Heart program proactively identifies a population at risk for or who have heart failure (HF). It is a continuum-based approach that allows interventions to be altered based on the severity of the patient’s illness. The program targets patients with ejection fraction (EF) <40% and heart failure patients who present with management challenges.

The Care of the Heart program staff support the provider’s plan of care by providing each actively enrolled member with a case manager, often a CCC-certified registered nurse, who can be accessed by a multi-disciplinary team working together to treat members with heart failure and help each member achieve the highest level of physical and psychosocial wellness. Members may contact their case manager any time they note a change in their condition.

Program Objectives

• Enhance communication between patients and health care providers.
• Promote cardiovascular risk factor modification in relation to medication compliance, smoking, depression and diet.
• Improve patient compliance related to symptom management, treatment management and self management.
• Maximize the effectiveness of therapy through increased education and positive reinforcement.
• Decrease health care costs through every intervention and proper utilization of resources.
• Increase patient and provider satisfaction.

Many heart failure patients have difficulty recognizing symptom exacerbations, and complying with diet restrictions and complicated medical regimens. Telephonic counseling includes disease-specific educational modules that focus on patient compliance with recommended treatment and self-care recommendations.

Case managers provide one-to-one interventions with members in the program, including:

• monitoring patient weight and other key symptoms of heart failure;
• assuring that patients are taking prescribed medications, including ACEI, ACEI substitute or ARB;
• assuring that patients are making wise nutritional choices;
• assuring that patients are exercising as directed;
• coordinating multiple services across multiple providers; and
• assessing functionality and compliance with treatment plan. (over)
  

Providers are advised of initial enrollment and program completion, as well as significant clinical events and/or status changes that are identified as part of the care coordination.

Telemonitoring
The Agency for Health Care Policy and Research (AHCPR) Guidelines for managing heart failure patients at home recommend that patients with HF weigh themselves daily, monitor key symptoms, and notify their provider immediately if a weight gain of more than 3 to 5 pounds has occurred since their last clinical evaluation. Unfortunately, many patients have a difficult time complying with prescribed monitoring and self-care regimens. Non-compliance with this guideline, and the resulting failure to recognize symptom changes before it is too late, are the key factors resulting in hospital re-admission.

Preferred Care provides a scale to each participating member free of charge. It may be standard, digital, talking, or another type of technology-based monitoring, depending on your patient’s needs. Providers may specify symptom changes, including weight fluctuations, about which they want to be alerted.

Improved Patient Outcomes
Patients report a high degree of satisfaction with the program and an increased ability to cope with their illness as a result of participation. Improved patient care resulting from enrollment in the program has reduced congestive heart failure hospitalizations by as much as 4%.

Providers are eligible for reimbursement upon completion of an enrollment form for each patient who:

• Meets program telephonic management criteria; and
• Successfully enrolls in the program.

How to Get Your Patient Involved

If you would like additional information about the Care of the Heart program or would like to refer a member for enrollment, please call the Preferred Care Care of the Heart Enrollment Specialist at (585) 327-2493 or 1-800-933-3920, ext. 2493.

Last updated : August 30, 2007