As U.S. healthcare trends toward team-based care with greater focus on preventive services, nurses are stepping into leadership roles and producing positive clinical outcomes. However, this shift in cardiovascular care may require an overhaul of cultures and systems by providers—as well as a fresh look at reimbursement.
Case management & preventive care
In its 2009 report, the World Health Organization estimated that deaths from cardiovascular disease (CVD) will rise to 23.4 million, an approximate 37 percent increase from 2004 rates, posing an ever-increasing burden of morbidity and mortality in both high- and low-income countries. To combat the problem in the U.S., medical home initiatives and reimbursement changes are driving CV care toward prevention as opposed to treatment. This type of case management will require healthcare professionals to consider psychological and behavioral aspects of care in addition to the knowledge of medicine.
“There is an enormous need for advanced coordinated care. Our current healthcare system with a single provider meeting with a single patient to take care of a single problem is just not efficient or effective,” says Kathy Berra, MSN, RN, ANP, clinical director at Stanford Heart Network in Stanford, Calif. She adds that nurses are trained for a coordinated-care approach. “If you’re a nurse practitioner in the U.S., you can diagnose and treat, and all nurses are taught to take a very holistic approach to care that incorporates the patient and family.”
If a patient needs to stop smoking but his or her significant other smokes, “then you have to deal with both of them or it’s less likely to be successful with that patient,” Berra explains.
And the evidence isn’t just anecdotal. In a large observational study of 193 Danish general practices assessing 12,960 patients with type 2 diabetes (age range 40 to 80 years), practices with well-implemented nurse-led type 2 diabetes consultations were compared with practices with no nurses for the hemoglobin A1c (HbA1c) scores of their patients as an indicator of outcomes (Primary Care Diabetes 2012;6:221-228). Only 17.2 percent of patients in the nurse-led case management arm failed to reach their HbAlc goal vs. 68 percent in the primary care arm.
Positive outcomes with nurse-led case management are not new. About 15 years ago, the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) at the University of California, Los Angeles, focused on the initiation of guideline-based therapies for CVD risk reduction in hospitalized patients with coronary artery disease (Am J Cardiol 2001;87:819-822). CHAMP demonstrated a significant reduction in morbidity and mortality in patients receiving nurse-directed case management compared with usual care one year after hospital discharge. This study became the cornerstone for the American Heart Association’s Get With the Guidelines initiative (Am Heart J 2010;159:207-214).
Despite this evidence, healthcare traditionally has been slow to change care delivery. Yet, the current confluence of events, along with the push to reduce healthcare costs, has escalated efforts to tackle new approaches. “Administrators are looking for cost-effective models of care, causing case management and transitional care models to gain prominence,” says Sandra B. Dunbar, DSN, RN, associate dean for academic advancement at Emory University’s School of Nursing in Atlanta. “They are recognizing the need for system changes, as well as role changes.”
Case management is particularly effective in preventive care, as it calls for a more holistic approach to a patient. “We currently have a crisis in secondary prevention, including obesity, lack of physical activity, smoking, high cholesterol, hypertension, diabetes and the aging of the population obviously complicates things as well,” Berra says. “Now, we’re going to need teams led by medical professionals, whether they are primary care physicians (PCPs), internists, nurse practitioners and nurses, who are then supported and work closely with nurses and other healthcare professionals, such as exercise physiologists, psychologists, nutritionists and physical and occupational therapists.”
She points to cardiac rehab as the best model because after a patient is hospitalized due to a heart condition, he or she is referred to a cardiac rehabilitation program for multifactorial management to reduce CVD risk. “This strategy has resulted in a 25 percent reduction in mortality,” Berra adds.
“A shift toward preventive services is tremendously important for improving long-term outcomes for patients,” says Dunbar. “And nurses have always had a great deal of exposure to wellness and prevention as part of their curriculum. As healthcare takes prevention outcomes more seriously, it is natural for nurses to promote and achieve optimal cardiovascular wellness.”
Heart failure and home care
Prevention isn’t the only area of CV management that benefits from nurse-led, collaborative care. Heart failure (HF) is under particular scrutiny due to the high rate of readmissions and tremendous cost burden to the U.S. system. In fact, HF is expected to increase by 25 percent over the next two decades at a projected cost of $77.7 billion (in 2008 dollars) (Circulation 2012;125:820-827).
A large meta-analysis, including 25 randomized controlled trials and 5,942 HF patients, assessed three different types of interventions: case management interventions (intense monitoring of patients following discharge often involving telephone follow-up and home visits); clinic interventions (follow-up in an HF clinic); and multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). Takeda et al found that nurse-led case management interventions led to decreased unscheduled HF readmission at six months and 12 months post-discharge (Cochrane Library, online Sept. 12). This study did not analyze 30-day readmission rates.
“A year after discharge, case management patients were less likely to be readmitted to hospital for any reason than people who received usual care,” the study authors wrote. Telephone follow-up by a specialist nurse was a common feature of the more successful programs.
Nurse interaction focused on the improvement and continual care of an HF patient in his or her home after discharge also has been shown to be effective. A landmark randomized clinical trial on HF patients at high risk of readmission found that nurse-directed intervention using home visits and telephone contact led to a reduction in all-cause readmissions by 28.5 percent and HF-related readmissions by 56 percent. It also reported improved quality-of-life scores at an estimated lower cost compared with a control group (N Engl J Med 1995;333:1190-1195). Due to the reduction in hospital admissions, the overall cost of care to the healthcare system was $460 less per patient in the nurse-directed treatment group.
More recently, McCauley et al examined how advanced practice nurses (APNs) coordinating patients’ transition from hospitals could prevent rehospitalizations and reduce costs compared with usual care (Dis Manag 2006;9:302-310).
“Patients with heart failure tend to have a lot of comorbidities in addition to heart failure, like diabetes or chronic lung disease,” says Kathleen M. McCauley PhD, RN, professor of cardiovascular nursing and clinical cardiology specialist at the University of Pennsylvania School of Nursing in Philadelphia. “For these patients, it’s most effective when nurses coordinate care.” For years, nurses have served as liaisons between HF physicians, pulmonologists and PCPs, even when “lines of communication weren’t great between those providers,” she adds. “You need someone to connect the dots of patients’ varied health problems.”
The trial examined 118 HF patients, many of whom had multiple comorbidities, over three months after discharge. The APNs visited the patient in his or her home within 24 hours of discharge, at least weekly for the first month and at least bimonthly for the next two months. Also, patients and caregivers could telephone the APNs between visits. At 52 weeks, intervention group patients had fewer readmissions (104 vs. 162) and lower mean total costs ($7,636 vs. $12,481).
“It remains to be demonstrated if appropriately prepared nurses without graduate nursing education could achieve similar outcomes,” McCauley et al wrote.
Due to new responsibilities and opportunities, Berra suggests nurses should receive a minimum of a bachelor’s degree going forward. “The higher the education of the nurse, the easier the transition will be for more active involvement in assisting in the care of patients on an inpatient and outpatient basis.” She adds that the complex nature of contemporary CV medicine requires a more advanced degree than in the past.
For those interested in leading prevention and case management teams, Dunbar recommends obtaining a degree, such as a clinical nurse specialist (CNS), a clinical nurse leader (CNL) or as an adult and family nurse practitioner (ANP/FNP). CNSs and CNLs primarily work in hospitals and medical centers, combining clinical practice with education, research, consultation and clinical leadership. They also assume roles of case managers, educators in hospitals or schools, and as managers or administrators in clinical or health plan settings. ANP/FNPs, who specialize in CVD to diagnose and manage CV problems for adults and children, typically work in community-based practice settings, including health clinics, corporate health, specialty clinics and private medical practices, as well as in research. A doctor of nursing practice (DNP) also adds skills related to systems, as well as strategies for improving quality and safety.
Dunbar adds that many of the nursing master’s programs offer leadership tracks about systems or organizational change, which can train nurses to lead interdisciplinary teams.
The reality is that until hospitals are incentivized to produce these outcomes, change will continue to be slow. “The Centers for Medicare & Medicaid Services could begin to thoughtfully approve reimbursement for nurses doing x, y or z, within certain prescriptive authority. But, that’s going to take us a long time,” says Berra. “Real systemwide reform is going to have to start with reimbursement; otherwise, the only people who will get this kind of care are those who can afford it out of pocket.”
One area that is ripe with opportunity is the ability for nurses to communicate with patients in their home electronically; however, reimbursement in the U.S. remains based primarily on in-person visits.
However, bundled payments—which are in the government reimbursement pipeline—will encourage hospitals to have a designated health professional ensure that when patients go home with the diagnosis of atrial fibrillation, ischemic heart disease or heart failure, they will see their providers and take their medications, says Berra. “This includes understanding whether the patient can afford the prescriptions he or she is being sent home with,” she adds.
McCauley concurs that the current fee-for-service model that reimburses hospitals for recurring events obstructs greater adoption of transitional care, which may prevent rehospitalizations, or preventive care, which may keep patients from having a catastrophic event.
“The bottom line is that nurse-led case management is successful—patients feel better and have better outcomes, while physicians and other healthcare professionals have improved job satisfaction,” Berra says. “All around, as a team, we can make the care process work much more efficiently. There are going to be bumps along the road, but we have to start now because what’s going on now is just not efficient or effective.”
|6 Principles of Nurse-Led Case Management for CVD Prevention:|
|1. Implement care according to evidence-based guidelines for cardiovascular disease (CVD) prevention;|
2. Target those who will benefit the most and take into account groups in which the prevalence of CVD and risk factors is highest;
3. Include families of high-risk patients;
4. Have an appropriate setting and a flexible approach that allows easy access to those targeted for the intervention;
5. Focus on promoting healthy lifestyle habits to address total CV risk; and
6. Have an effective mechanism for prescribing and managing cardioprotective medications.