Keywords

case management, disease management, heart failure

 

Authors

  1. Annema, Coby MSc, RN
  2. Luttik, Marie Louise PhD, RN
  3. Jaarsma, Tiny PhD, RN

Abstract

The management of patients with heart failure (HF) is complex and often benefits from a patient-tailored approach. Since the early 1990s, HF disease management programs have been developed and implemented to improve outcomes of patients with HF. The body of evidence of the effectiveness of these programs is still growing, but meta-analyses of disease management program studies show various results on outcomes. This raises questions regarding the optimal organizational structure and components of a most cost-effective HF management program. Case management has been described as a solution to improve outcomes in complex patients and as a possible link to effective disease management. This raises the question of what case management can add to the disease management of patients with HF and which patients might benefit. The aim of this article is to discuss the potential contribution of case management in the disease management of patients with HF.

 

Article Content

The management of patients with heart failure (HF) is complex and often needs a patient-tailored approach. To improve outcomes for patients with HF, it is recommended that the care for these patients be organized in a system of specialist HF care: a so-called disease management program.1

 

Since the early 1990s, HF disease management programs have been developed and implemented in countries across Europe, North America, and Australia.2,3 The body of evidence of the effectiveness of these programs is still growing. Meta-analyses of disease management program studies show various results on outcomes such as hospitalization, mortality, and healthcare costs.4-6 At the same time, questions arise regarding the optimal organizational structure and components of a most cost-effective HF management program.7

 

Congruently, case management as another way to organize care has been described as a solution to improve outcomes in complex patients and as a possible link to effective disease management. This raises the question of what case management can add to the disease management of patients with HF and which patients might benefit. The aim of this article is to discuss the potential contribution of case management in the disease management of patients with HF.

 

Disease Management in HF

Disease management is an approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across healthcare delivery systems8 and refers to multidisciplinary efforts to improve the quality and cost-effectiveness of care for select patients with a specific chronic illness.9,10 In these programs, the course of the disease-HF-is the central point of application.

 

The following are recommended components of a HF disease management program by the European Society of Cardiology:

 

[black small square] a multidisciplinary approach by physicians, nurses, and other related services

 

[black small square] first contact during hospitalization and early follow-up after discharge

 

[black small square] target high-risk, symptomatic patients

 

[black small square] increased access to healthcare

 

[black small square] facilitate access during episodes of decompensation

 

[black small square] optimization of medical management

 

[black small square] access to advanced treatment options, adequate patient education with emphasis on adherence and self-care management

 

[black small square] patient involvement in symptom monitoring and flexible diuretic use

 

[black small square] psychosocial support to patients and their family and/or caregiver1

 

 

Although other models exist, most HF disease management programs are situated in an HF clinic: Service is provided in an outpatient clinic setting where patients receive care from practitioners with expertise in HF.2 Different healthcare providers are involved in the care at the HF clinic (Figure 1), but the size and structure vary depending on the local situation.11 Heart failure disease management programs also vary in their mode of follow-up used, from primarily telephonic to largely in-person contact. Heart failure disease management programs mostly focus on adherence to lifestyle changes, symptom recognition by patients, and consultation with a healthcare professional for changes in symptoms. In addition, optimization of medical treatment is a component in several HF clinics.

  
Figure 1 - Click to enlarge in new windowFIGURE 1. Traditional heart failure clinic according to Erhardt and Cline.

Recent studies show that HF disease management programs cannot always decrease readmission.12-14 This indicates on the one hand that adverse outcomes of these severely affected chronically ill patients cannot always be prevented. On the other hand, it might be necessary to adopt new strategies to improve outcomes instead of increasing the intensity of the different components of disease management programs.

 

Case Management for HF

Case management developed from roots in nursing and social work. Case management is concerned with optimization of multidisciplinary treatment for complex patients and with the integral needs of individual patient without focusing on only one specific illness or population as in disease management.15 In case management, the needs of the individual patient are the central issue instead of the disease.

 

Core elements of the case management process are assessing patient needs, developing an individualized treatment plan with the patient, and helping patients with the implementation of the treatment plan. Additional elements include coordinating care by timing delivery of various components and coordinating care between different providers, intensively monitoring the care process by reviewing adherence of the patient to the treatment plan, monitoring whether treatment goals are achieved, and evaluating care.16 The care is often delivered in a patient advocacy model that emphasizes the coordination of services from the client perspective. The treatment regimen is determined not only by the medical needs but also by the financial, psychological, and social circumstances of the patient.17

 

Although disease management programs for patients with HF comprise elements of a case management approach, by individualizing education and counselling to the patients needs, the nature of disease management programs remains disease oriented. The integrated approach of a case manager to addressing all the needs of an individual can be helpful for patients with HF for several reasons.

 

First, the complete structured and formalized assessment of all health risks, clinical, psychosocial, and environmental, used in case management may be a way to effectively manage the disease course of patients with HF. Based on this comprehensive assessment, appropriate actions can be undertaken to improve or prevent health problems and also help the patients with their social and financial concerns. In this process, the case manager can be the central point of all clinical and nonclinical interventions.

 

Second, comorbidity is an important related factor in HF. Diabetes (20%-30%), chronic obstructive pulmonary disease (20%-30%), anemia (20%-30%), and renal dysfunction often coincide with HF.12,18,19 It seems desirable to involve other medical specialties in the disease management program of patients with HF. Parallel with HF disease management programs, the care for patients with chronic illnesses like diabetes or chronic obstructive pulmonary disease can also be organized in disease management programs,20,21 making the organization context for an individual patient with comorbidity very complex. In a case management model, the care for patients with multiple chronic conditions can benefit from an individualized treatment plan based on the different disease management programs because it is directed not only at HF but also at all other comorbidities (Figure 2). A case manager can manage the integrated care plan based on the expertise, opinions, and possibilities of the different specialties.

  
Figure 2 - Click to enlarge in new windowFIGURE 2. Case management within disease management programs. COPD indicates chronic obstructive pulmonary disease.

Third, it is recommended that HF management programs include integration and coordination of care with the patient's general practitioner and with other agencies. In the current practice, this is often not organized in a structured manner. Most HF management programs do not have a structured contact within primary care.2 The coordinative task of the case manager could provide for this recommendation by coordinating the total care for an individual patient within and outside the hospital.

 

Fourth, although services like telephone contact, telemonitoring, and outpatient clinic visits are used as well in disease management, the outreach to the patient and his/her social environment seems to be more intense in the case management model. The continuous monitoring and intensive follow-up and the use of home visits may enhance outcomes for patients with HF because patient education and symptom self-management seem to be particularly effective when they are at least partly delivered in a patient's own home.22

 

Finally, HF affects the lives not only of patients but also of their partners and/or caregivers.23 Partners and/or caregivers should become actively involved in the caregiving process. In case management, the patient and their caregivers are actively involved. Integrating case management into the disease management of patients with HF can involve patients with HF and their caregivers in the care process.

 

Based on the evidence, case management may be a way to optimize disease management in patients with HF, by changing the focus from disease-oriented to patient-centered care, intensifying outreach to the patient and his/her social environment, and integrating the care for a patient not only within the medical specialty of HF but also between different medical specialities and across healthcare settings (Figure 3).

  
Figure 3 - Click to enlarge in new windowFIGURE 3. Proposed heart failure management.

Does Every Patient With HF Need a Case Manager?

At this time, there is no evidence of the effect of case management on outcomes in patients with HF.17 In addition, questions about the practical application of case management within a disease management program remain. Questions about which patients should be included in a case management program, how the case management program should be designed, the position of the case manager in the healthcare system, and who should be the case manager still need to be answered.

 

A "one-size-fits-all concept" is not sufficient to meet the needs of all patients with HF and to attain positive outcomes related to mortality, hospitalization, and quality of life. A flexible program that can adapt to patients' individual circumstances may be the most efficacious approach. In our opinion, patients whose conditions are not complex and who are at low risk for deterioration can benefit from HF care based on a disease management program directed at one specific illness. Only those patients at high risk for deterioration and with several comorbidities will probably need intensive case management, continuous monitoring, and intensive follow-up for a prolonged period of time. Regarding the organization of case management for patients with HF, the optimal mix of available services (home visits, telephone contacts, and outpatient clinic) that will meet the patient's needs in an efficient way and lead to successful outcomes has to be explored.

 

Because healthcare is a complex environment in which tasks overlap between healthcare providers, the position of the case manger has to be clear and supported by all the healthcare providers involved. Case managers must obtain all parties' agreement to participate in disease management programs.

 

Finally, the question about who should be the case manager has to be addressed. Not only whether the case manager should be independent or be part of the healthcare delivery system, but also which healthcare provider is most capable to fulfill the role of case manager must be answered. Should this be a cardiologist, the HF nurse, a social worker, or the general practitioner?

 

Conclusion

In complex patient situations, providers should consider moving away from the traditional HF disease management approach in which multiple conditions are individually managed. Instead, they should recognize the importance of integrated management of several comorbidities and initiate a management strategy tailored to the individual patient situation.

  
TABLE. No caption av... - Click to enlarge in new windowTABLE. No caption available

Case management might be integrated in disease management programs and could provide advantages for patients with HF, mainly by changing the focus from disease-oriented to patient-centered care. Patients who are in need of highly individualized, coordinated, and integrated care may benefit from this approach. However, it is important to identify patients who will clinically and financially benefit most from care provided by a case manager. As in disease management, case management requires the dedication of health professionals, patients, and their partners and/or caregivers to make it work. Research on the effect of a case management approach on the outcomes for patients with HF is needed to establish the value of case management for patients with HF.

 

References

 

1. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJV, Ponikowski P, Poole-Wilson PA. The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure Eur J Heart Fail 2008;10:933-989. [Context Link]

 

2. Jaarsma T, Stromberg A, De Geest, et al. Heart failure management programmes in Europe. Eur J Cardiovasc Nurs. 2006;5(3):197-205. [Context Link]

 

3. Driscoll A, Worral-Carter L, McLennan S, Dawson A, O'Reilly J, Stewart S. Heterogeneity of heart failure management programs in Australia. Eur J Cardiovasc Nurs. 2006;5(1):75-82. [Context Link]

 

4. McAlister FA, Lawson FME, Teo KK, Armstrong PW. A systematic review of randomized trials of disease management programs in heart failure. Am J Med. 2001;110(5):378-384. [Context Link]

 

5. Ofman JJ, Badamgarav E, Henning JM, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med. 2004;117(3):182-192. [Context Link]

 

6. Whellan DJ, Hasselblad V, Peterson E, O'Connor CM, Schulman KA. Meta analysis and review of heart failure disease management randomized controlled clinical trials. Am Heart J. 2005;149(4):722-729. [Context Link]

 

7. Clark AM, Thompson DR. The future of management programmes for heart failure. Lancet. 2008;372(9641):784-786. [Context Link]

 

8. Ellrodt G, Cook DJ, Lee J, Cho M, Hunt D, Weingarten S. Evidence-based disease management. JAMA. 1997;278(20):1678-1692. [Context Link]

 

9. Krumholz HM, Currie PM, Riegel B, et al. A taxonomy for disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group. Circulation. 2006;114(13):1432-1445. [Context Link]

 

10. Faxon DP, Schwamm LH, Paternak RC, et al. Improving quality of care through disease management. Principles and recommendations from the American Heart Association's Expert Panel on Disease Management. Circulation. 2004;109(21):2651-2654. [Context Link]

 

11. Erhardt LR, Cline CM. Organisation of the care of patients with heart failure. Lancet. 1998;352(suppl I):SI15-SI18. [Context Link]

 

12. Jaarsma T, Van der Wal MHL, Lesman-Leegte I, et al. Effect of moderate or intensive disease management program on outcome in patients with heart failure. Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure (COACH). Arch Intern Med. 2008;168(3):316-324. [Context Link]

 

13. Coletta AP, Cleland JG, Cullington D, Clark AL. Clinical trials update from Heart Rhythm 2008 and Heart Failure 2008: ATHENA, URGENT, INH study, HEART and CK-1827452. Eur J Heart Fail. 2008;10(9):917-920. [Context Link]

 

14. Jaarsma T, van Veldhuisen DJ. When, how and where should we "coach" patients with heart failure: the COACH results in perspective. Eur J Heart Fail. 2008;10(4):331-333. [Context Link]

 

15. Latour CMH, Van der Windt DAWM, De Jonge P, et al. Nurse-led case management for ambulatory complex patients in general health care: a systematic review. J Psychosom Res. 2007;62(3):385-395. [Context Link]

 

16. Thurkettle MA. Case management: a contemporary view. In: Huber DL, ed. Disease Management. A Guide for Case Managers. St Louis, MO: Elsevier Saunders; 2005:32-40. [Context Link]

 

17. Zwarenstein M, Stephenson B, Johnston L. Case management; effects on professional practice and health care outcomes (protocol). Cochrane Database Syst Rev. 2000;(4):CD002797. doi10.1002/14651858.CD002797. [Context Link]

 

18. Dahlstrom U. Frequent non-cardiac co morbidities in patients with chronic heart failure. Eur J Heart Fail. 2005;7(3):309-316. [Context Link]

 

19. Hogenhuis J, Voors AA, Jaarsma T, et al. Anaemia and renal dysfunction are independently associated with BNP and NT-proBNP levels in patients with heart failure. Eur J Heart Fail. 2007;9(8):787-794. [Context Link]

 

20. Taylor SJC, Candy B, Bryar RM, et al. Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence. BMJ. 2005;331(485). doi: 10.1136/bmj.38512.664167.8F. [Context Link]

 

21. Knight K, Badamgarav E, Henning JM, et al. A systematic review of diabetes disease management programs. Am J Manag Care. 2005;11(4):242-250. [Context Link]

 

22. Holland R, Battersby J, Harvey I, Lenaghan E, Smith J, Hay L. Systematic review of multidisciplinary interventions in heart failure. Heart. 2005;91(7):899-906. [Context Link]

 

23. Luttik ML, Blaauwbroek A, Dijker AJM, Jaarsma T. Living with heart failure: partner perspectives. J Cardiovasc Nurs. 2007;22(2):131-137. [Context Link]