CareSupport initiative focuses on CHF

The patient is in the hospital for congestive heart failure. Perhaps the doctors and nurses need to give care instructions through an interpreter. But now it’s time to go home.

Maybe home means cold and hunger because of poverty. Maybe at home family members can’t give all the help that’s needed.

In circumstances similar to these, the odds are very good the patient won’t have adequate support and faces increased risk of ending up back in the hospital… or worse.

That’s not unusual for members who are part of CareOregon’s Living with CHF Program. That’s why, since February, the CareOregon CareSupport Unit has focused special attention on members with CHF.

“Our pilot is targeted at members who have been hospitalized with a primary diagnosis of CHF,” says Rebecca Ramsay, CareSupport Unit Manager. “However, any member who needs this kind of support can get it.”

Members enrolled in the CHF program also will receive assistance and support for other risks they have as part of the comprehensive CareSupport program. The goal is to give members the support they need to reduce the likelihood they’ll end up back in the hospital.

“Overwhelmed” members and caregivers receive help

Ten of Margaret Wheelhouse’s 43 patients have CHF. Margaret is a CareSupport Health Care Guide. Her team includes a behavioral specialist and a nurse. They also work with pharmacists and health education staff to make sure members get the extra support they need for their recovery or maintenance.

Margaret Wheelhouse, Health Care Guide for CareOregon's CareSupport Unit Photo by Eleanor Gorman

Margaret’s first contact with the patient comes a few days after hospital discharge. If she needs to, she'll speak to the patient through an interpreter or family member. It’s not an intrusive call. It’s just to learn how everything is going, find out a little about the home circumstances, and develop rapport with the member.

“The first reaction is, ‘Why is the insurance company calling me? Am I in trouble?’” Margaret says. “Then it goes to, ‘Oh, thank you so much. We didn’t know you were there and could help us.’”

Margaret learns the family is overwhelmed.

“They know they need to weigh her every day, but they don’t have a scale.”

They are grateful to learn that CareSupport will send a scale and a visual guide on caring for CHF at home.

A few days later, Margaret follows up with a second call. She goes over the material in the guide booklet, and talks to patient and caregivers about the nuts and bolts of living with CHF.

She asks if they understand how to take the medications that have been prescribed. She talks about the three “zones” of symptoms—green, yellow and red—that tell them to take extra steps, such as getting medical care when their symptoms are growing worse.

“They know she needs to be on a low-sodium diet, but they don’t know what that means,” Margaret says. “So I explain it.”

Margaret learns that the patient’s caregivers work away from home.

“We’ll get them connected with Aging & Disability Services,” Margaret says. “And we’ll talk with the PCP about a determination of medical necessity for a nurse for short-term care.”

Someone on the CareSupport team contacts the patient by phone at least once a week. Sometimes, just the phone call is a lot of help.

“Many of them don’t have support or they have mental health issues,” Margaret says. “So by us calling, it’s like a social call. It gives them a sense that ‘Somebody cares about me.’ And that has a huge impact for them.”

CareSupport team works with PCPs

Margaret’s team contacted the primary care provider as soon as the member was identified as a good candidate for CHF-focused care support. They’ve discussed how CareSupport can work with the provider to help implement the treatment plan.

“Everything I tell the patient comes from the doctor,” Margaret says. “But I can spend an hour on the phone talking to them and the doctor can’t.”

It’s very important to know that this is not a separate disease management program, Rebecca says.

“We continue to give comprehensive support, with an additional focus on self management of CHF that is designed to complement the provider’s treatment plan,” she says.

And that is appreciated by the providers whose patients are a part of the program.

“My first impression is, fantastic, very helpful,” says Barbara Martin, MS, PA-C. At Central City Concern’s Old Town Clinic, Barbara has two patients who recently received CHF care support.

“Talking and coaching is really helpful,” she says. “Having a scale is huge. It really helps for someone to weigh themselves every day.”

Providers may request CareSupport attention

The first participants in the CHF program were identified when they were discharged from the hospital. The pilot project will study outcomes from this group to measure the program’s effectiveness.

But CareSupport’s CHF services aren’t limited to those who have been hospitalized.

“We want providers to call us with patients they think should have this attention,” Rebecca says. “And we want input and feedback on how it’s going.”

Providers who have such input should contact Rebecca at ramsayr@careoregon.org. Providers with a CareOregon member who would be a good candidate for the CHF program should contact Tareyn Tamez by telephone, 503-416-5753, or e-mail tamezt@careoregon.com.