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MEDICALMANAGEMENTPROGRAM|SECTION7 Chronic Cardiac Conditions Programs TheChronicCardiacConditionsProgramsaredesignedtomodifycardiovascularriskfactorsandslow diseaseprogressionformemberswithheartfailureandischemicheartdisease.Thisisaccomplishedby promotingtreatmentplancompliancethrougheducation,counseling,andsupport.Programgoals include: • Reversalorstabilizationofsymptoms • Optimizationoffunctionalcapacity • Improvementofqualityoflife • Reductioninfrequencyofhospitalization • Facilitationandenhancementofthepatient/doctorrelationship Program Content MemberidentificationisconductedbyICD-10analysisofambulatoryandinpatientclaimsandinpatient DRG127.Diagnosiscodesinclude:I21,I22,andI24forischemicheartdiseaseandI501forheartfailure. Othermethodsofmemberidentificationincludehealthriskscreeninganddirectreferralbytheprimary carephysicianorcardiologist.MemberstratificationisbasedonseverityofillnessusingNewYorkHeart Associationclassification. Thechronicheartfailureprogramreliesonpopulation-basedmeasuresofassessmentofleftventricular function,ACEinhibitoruse,andhospitalizationutilization.Thesamemeasuresareusedattheindividual memberlevelforthosemembersstratifiedashigh-riskandwhoparticipateinTheHealthPlan’s telephonicchronicheartfailureprogram.Primaryattentionispaidtotheapplicationofappropriate pharmacologicaltherapiesincludingtheuseofACEinhibitorsandbeta-blockers,enhancementofselfmanagementskills,andsystematicsurveillanceofthosewithsymptomaticheartfailuretoprevent hospitalization. TheIschemicHeartDiseaseProgramreliesonpopulationbased-HEDIS®(1)measureofbetablocker usageforsixmonthsafteradischargeforAMI.Thesamemeasuresareusedattheindividual memberlevelforthosemembersstratifiedashigh-riskandwhoparticipateinTheHealthPlan’s telephonicischemicheartdiseaseprogram.Primaryattentionispaidtotheapplicationof appropriatepharmacologicaltherapies,lifestylemodification,enhancementofself-management skills,andsystematicsurveillanceofthosewithsymptomaticischemicheartdiseasetoprevent hospitalizationoracutecoronaryevent. Population-basedchronicdiseasenavigationstrategiesincludetargetededucationalmailings throughouttheyear.High-riskmembersreceivetelephonicchronicdiseasenavigationinterventionfrom acardiacnursenavigatorwhoprovidesindividualizedinterventionsthatincludetheevaluationof appropriatemedicationuse,education,andcounselingaboutdailyself-management,andmember MEDICALMANAGEMENTPROGRAM|SECTION7 recognitionofearlysignsandsymptomsrequiringintervention.Enrolledmembersreceivehomescales, referralsfornutritionaleducationtoaddressdietarycompliance,referralsforhomeoxygen/respiratory therapywhenindicated,andimmunizations.Considerationofotherhealthconditions,suchasdiabetes andchronicobstructivepulmonarydiseaseareincludedinthemanagementprogram. Conditionmonitoringandsurveillanceareongoingandproactive.Callsarescheduledatperiodic intervals.Detailedquestionsareaskedaboutthepatient’sconditionandinformationisgatheredabout patientstatus,treatmentplanadherence,functionalstatus,andqualityoflife.Aspecificplanofcareis developedbasedonpracticeguidelinesfromtheACC/AHA“GuidelinesfortheEvaluationand ManagementofChronicFailureintheAdult.”Ongoingmonitoringbythechronicheartfailuremanager ensurestimelyinterventionwhenachangeinriskstatusisidentified.Thefrequencyofoutboundcallsto membersbythenursenavigatorisdeterminedbythemember’sseverityofsymptoms. Thismayresultindailycontactintimesofhigh-riskorconcernaswellsasconsultationswiththe physician.Whenhomecareisneeded,thenursenavigatorworkswiththephysicianandhomecare agencytocoordinatethenecessarycareandservices. Amajorcomponentofthechronicheartfailureprogramistheempowermentofthememberthrough education.Avarietyoftopicsareaddressedinbothinitialandreinforcementteaching.Patient educationmaterialsareprovidedtoeachpatientthroughouttheprogramandareusedintheteaching process.Thesewarningsignsarereviewedwitheachassessmentcallalongwithareviewofmedications andmedicationcompliance.Lifestyleissuesareaddressedthrougheducationandincludethe appropriatenessofexercise,diet,self-managementskills,andwhenindicated,smokingcessation interventions.Patientsareencouragedtokeeparecordoftheirdailyweightandtonotifythephysician iftheyexperienceaweightgainoftwopoundsinonedaytothreepoundsinoneweek. Asuccessfulchronicheartfailureprogramisdependentonthecoordinationofhealthcareservices.The roleofthephysicianisvitalandthisprogramisintendedtocomplimentthemedicalcarethememberis receivingfromhis/herphysician.Thegoalofthemanagementprogramistofosteracollegial relationshipbetweenthephysicianandthenursecarenavigatorinordertocoordinatethenecessary andappropriatecareforthemember.Evidence-basedguidelinesareavailable,distributedregularly, andrecommendedfortheusebythephysiciantomedicallymanagetheirpatientswithchronicheart failure.
