Nursing Center - Journal Article

Keywords: case management, disease management, heart failure

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.

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 systems 8 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 caregiver 1

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 window

FIGURE 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 window

FIGURE 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 window

FIGURE 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.

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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.