The Stanford Chronic Care Management System

Implementation

Implementing SCCMS

Patients who have received ER or hospital care for acute coronary syndromes (ACS) often delay in seeking prompt help for subsequent cardiovascular symptoms. The Stanford Chronic Care Management System (SCCMS) incorporates patient-related and system-related initiatives to improve the care of patients treated for suspected ACS:

  1. A behavioral intervention provided by the nurse care manager at a baseline visit helps patients to overcome obstacles to calling promptly for help when they experience symptoms.
  2. A systems redesign provides ongoing telephone access to the nurse care manager and cardiologist on a 24/7 basis and a web-accessible clinical research database provides immediate access to updated patient-specific data.
    • In the event of recurrent symptoms, patients at high risk of ACS are directed by SCCMS staff to contact 911.
    • Patients at moderate risk of ACS are scheduled to attend a same-day cardiology clinic.
    • Patients at low risk of ACS receive telephone guidance and follow-up.
    • All patients initiating a telephone contact with SCCMS staff through a 1-800 number to report cardiovascular symptoms receive a telephone follow-up call at 24 hours and their physicians receive a printed medical status report.

How SCCMS is implemented

Components of SCCMS

A. Baseline telephone instruction by nurse care manager

B. Routine out-bound (nurse-initiated) telephone contacts at 1, 2, 3 months and quarterly thereafter to study end

C. In-bound (patient-initiated) telephone access 24/7

D. Advice provided by nurse care managers and cardiologists: Stay at home + 24 hour phone follow-up

E. Visit a same-day cardiology clinic + 24 hour phone follow-up - Summon EMS (911) for ER visit + 24 hour phone follow-up

A. Baseline Telephone Instruction

Prior to baseline telephone instruction, patients will view an instructional video or DVD portraying SCCMS in action. This is provided by the research assistant during hospitalization or is sent via express mail to patients immediately after hospitalization. As soon as possible after randomization, the nurse care manager telephones the patient to assure that the patient has viewed the instructional materials, reviews patients' current medical status based on data entered by the research assistant into the clinical research database, instructs the patient on the intervention, provides the 24/7 telephone contact number, and establishes a schedule for routine follow-up telephone contacts. Family members and caregivers are encouraged to participate in this baseline telephone instruction.

Instruction provided to patients and family members is designed to help patients distinguish between cardiovascular and non-cardiovascular symptoms and establish the need for a prompt response to cardiovascular symptoms. Nurse care managers will work closely with primary physicians to ensure that patients are prescribed combination pharmacotherapy (aspirin, beta blocker, statins, ACE inhibitors) and nitroglycerin in accordance with ACC/AHA guidelines. Nurses will assist patients to achieve optimal doses of medications, including antiplatelet and antianginal agents, and will instruct patients in the appropriate use of nitroglycerin.

Nurse care managers strategize with patients and family members on procedures for establishing timely telephone contact with SCCMS staff in case of symptoms of concern and describe how SCCMS staff will communicate with the patient's physician by telephone, and printed reports. Patients are oriented to the procedure for initiating a simulation telephone contact with the nurse care manager between 8 a.m. and 5 p.m., Monday-Friday, in the two weeks following the baseline telephone contact. Patients are oriented to the procedures for the same-day cardiology clinic . Finally, patients are provided with a 24/7 telephone access number (1-800) for the nurse care manager and the cardiologist and a schedule of routine nurse-initiated follow-up telephone contacts. To facilitate immediate telephone access to SCCMS when patients are away from their land line telephones, patients who own a cell phone are urged to carry it. Patients are advised that emergency crews responding to emergency (911) telephone contacts require a land line connection with the caller.

B. Routine Outbound (nurse-initiated) Follow-up Telephone Contacts

During these contacts, initiated at 1, 2, 3 months and quarterly thereafter, nurses will follow a standard protocol to evaluate patients' symptoms, review their medications, and obtain results of specialized tests, including ECG's, that have been obtained since the previous contact. These data are recorded electronically on a telephone contact form and the procedures and tests results form. Nurse care managers will inquire about any clinic visits, ER visits, or rehospitalizations since the previous telephone contact and will contact physicians, ER's, or hospitals to obtain a copy of the latest ECG, which will be scanned and uploaded to the clinical research database. Patients reporting worsening of symptoms during these telephone contacts may receive additional nurse-initiated telephone contacts and may undergo additional diagnostic testing, visits to their physicians, or dose adjustment of their anti-anginal medications.

The role of the database application in coordinating the care provided by SCCMS staff is shown in Figure 1. The database contains data abstracted from hospital medical records , clinic and ER visits by research assistants and augmented by data obtained during telephone contacts between patients and SCCMS staff and from subsequent EMS, ER, and hospital records. Medical status reports generated by the database are provided to SCCMS staff and community physicians as needed to facilitate patient care.

During clinic hours, the nurse care managers and cardiologists can access the clinical research database from their offices and clinics. After hours, cardiologists use wireless telephones to access the clinical research database containing current data on patients' current medical status. The database will alert SCCMS staff through text messaging that there is patient activity to be reviewed. Alarms embedded in the database also remind SCCMS staff to initiate follow-up contacts at 24 hours.

C. Inbound (Patient-Initiated) Telephone Contacts

Patients are provided with a 1-800 telephone number that connects them to the nurse care manager Monday-Friday 8 AM – 5 PM. After four rings, calls are automatically forwarded to the cardiologist on "first call", then to the cardiologist on "second call". If there is no answer from any of the three SCCMS staff within 10 minutes, patients are instructed to call again. In the rare case in which patients do not reach the nurse care manager or either of the two program cardiologists by telephone within 20 minutes during clinic hours , or the cardiologist after hours , patients are advised to call 911.

D. Advice Provided to Patients Initiating Telephone Contact

Decision-making by SCCMS staff is based on AHA/ACC guidelines for STEMI and non-STEMI/unstable angina. Important features of baseline risk established upon enrollment include previous MI and the extent of left ventricular dysfunction and/or myocardial ischemia. Important features of the interval history since the patient's last contact with SCCMS staff include:

  1. Frequency and severity of chest pain and other cardiovascular symptoms and changes in the pattern and dosage of anti-ischemic medications.
  2. Frequency of unscheduled medical contacts prompted by new or worsening cardiovascular symptoms, including ER visits, hospitalizations, and patient-initiated telephone contact with the physician, and
  3. Patients' reports of the results of any diagnostic tests.
  4. Based on the work of Allison et al. and our pilot studies cited previously, as many as 200 of 900 patients receiving SCCMS (22%) are expected to experience recurrent cardiovascular symptoms in the year after enrollment. In approximately 20 such patients (10%, not shown in the figure), symptoms will be severe and rapidly progressive, irrespective of baseline risk. Those patients will be instructed during the baseline telephone session to contact EMS directly rather than through SCCMS.

    The estimated flow of patients initiating telephone contacts to SCCMS staff to report cardiovascular symptoms, the triage recommendation, and the final patient disposition are shown in Figure 2.

    Of the remaining 180 patients shown in Figure 2, approximately 40 will have low baseline risk, a stable clinical course, and mild symptoms that are often non-ischemic. The triage recommendation for these patients will be to stay at home , adjust medications and schedule clinic visits or follow-up testing such as treadmill testing as appropriate. They will be advised that worsening symptoms or recurrence of symptoms prior to a telephone contact from SCCMS staff at 24 hours should prompt another telephone contact to SCCMS. As many as 10% of these patients (i.e. 4) may experience recurrence or worsening of symptoms requiring a same-day cardiology clinic or ER visit.

    Approximately 100 patients calling during clinic hours because of mild to moderate cardiovascular symptoms and a moderate risk at baseline will be advised to attend a same-day cardiology clinic if they can arrive by 4:30 pm. If this is not possible, they are advised to call 911 for transportation to the ER. Such clinics are presently operational in most medical centers. Approximately 60% of these patients will be discharged home and 40% will be hospitalized for evaluation. Finally, approximately 40 patients with high risk at baseline and mild to moderate cardiovascular symptoms are advised to call EMS for transport to the nearest ER. In all cases, patients retain the prerogative to call EMS at any time.

    Emergency telephone staffing.

    The maximum rate of "emergency" patient-initiated telephone contacts achieved by the end of the second year and maintained throughout the third year, is approximately 100 per month or 25 per week or 5 per day. Scheduled-nursing effort of 160 hours per month in each site is commensurate with this need. Based on data obtained in the pilot implementation project at PAVAHS, at least three-quarters of these unscheduled (patient-initiated) telephone contacts are expected during clinic hours, when nurse care managers are available. One-quarter of them are expected after hours, when cardiologists are available. Thus, SCCMS cardiologists may receive up to 25 patient-initiated telephone contacts each month or 6 per week or fewer than one per day . In the pilot study, non-urgent telephone contacts with cardiologists were infrequent and were rarely made after hours. SCCMS cardiologists' effort, scheduled at 20% FTE, at the discretion of the site investigator, is commensurate with this need. Even if twice as many patients initiated telephone contact because of cardiovascular symptoms, staffing of SCCMS would be adequate to meet the need. Based on pilot studies, patients in the treatment group are expected to initiate an additional 200 non-emergency telephone contacts during the course of the clinical trial to obtain information on follow-up clinic visits with their physicians and resolve questions about drugs and the outcomes of specialized tests. These non-urgent issues will be largely referred to the primary physician. They may also be addressed during routine nurse-initiated follow-up telephone contacts at 1, 2, and 3 months and quarterly thereafter.

    All inbound telephone contacts to report cardiovascular symptoms are documented in the clinical database using the Telephone Contact form . Patient-initiated telephone contacts trigger a medical status report that includes symptoms, medications, and the most recent ECG available in the database. This report is distributed to the patient's physician in electronic or in printed format 24 hours later.

    E. Same-Day Cardiology Clinic

    After the patient is triaged to this clinic by telephone, the nurse care manager apprises the patient's SCCMS cardiologist by telephone of the patient's imminent arrival in the clinic. He or she then prints out a medical status report and the most recent ECG stored in the database, and visits the clinic to secure a room for the patient. Immediately after the patient's arrival, the nurse care manager records an ECG and assesses the patient's clinical status. If the patient is clinically stable, the nurse care manager leaves the patient under the customary surveillance provided in the clinic and takes the medical status summary and the ECG's to the SCCMS cardiologist to discuss the case. If the cardiologist wishes to order a plasma troponin test on a clinically stable patient undergoing evaluation in the same-day cardiology clinic, the nurse care manager draws a blood sample, performs a point-of-service troponin test, and telephones the SCCMS cardiologist with the results. The cardiologist discharges the patient home or admits him or her to the hospital.

    If the patient's symptoms have worsened or the patient appears ill on presentation to the same-day cardiology clinic, the nurse care manager immediately arranges for the patient's transport by gurney to the ER. He or she accompanies the patient to the ER and takes the medical status report and the newly-recorded ECG to the ER physician, who coordinates the patient's subsequent management with the patient's cardiologist. The SCCMS cardiologist maintains responsibility for the patient's care throughout the course of the patient's evaluation. The cardiologist bills for these services, which are provided as part of the usual care provided to the patient.

    On the following day, the nurse care manager telephones the patient to determine his or her medical status, enters the relevant data into the database, and sends an updated medical status report to the SCCMS cardiologist and the patient's primary physician and/or cardiologist. The total number of same-day cardiology clinic visits is projected to be only 100 (see Figure 2). Even if this number were increased two or three-fold, it represents a small commitment of cardiologists' effort.

    Costs and Potential Savings of SCCMS

    We expect that SCCMS will reduce unnecessary ER visits, and many of the hospitalizations that follow them. To estimate the potential reduction in costs resulting from SCCMS, we obtained data from Stanford Hospitals and Clinics (SHC) on charges, net revenue and costs for ER and subsequent hospital care provided to 100 consecutive patients with suspected ACS. The charges for an ER visit were approximately $5,000, including nursing surveillance, diagnostic tests, drugs and physician fees. SHC recovers approximately 37% of this amount, or approximately $2,000, from third parties, including Medicare. The cost of providing this care is approximately 80% of this figure, or $1,600. Hospital charges for these patients averaged $12,000, of which SHC recovers approximately 30%, or $3,600 from third parties. The cost of providing this care is approximately 80% of this amount, or $2,800. Physician charges for a cardiology clinic visit at SHC range from $200 to $500, depending on the complexity of the case. Assuming that patients seen on an expedited basis in the same-day cardiology clinic fall into the higher billing category and also require an ECG and other tests, the total charge for a same-day cardiology visit is approximately $1,000, of which SHC recovers approximately 37%, or $370. The costs of providing this care are approximately 80% of this figure, or $300 per patient.

    We project that at least 50 of the 200 patients presently undergoing ER evaluation for suspected ACS as part of their usual care (25%) could attend a same-day cardiology clinic or stay at home instead. Indeed, data from the pilot study of SCCMS implementation at PAVAHS showed a much greater reduction in ER visits. The estimated flow of patients initiating telephone contacts to SCCMS staff to report cardiovascular symptoms, the triage recommendations, and the final disposition are shown in Figure 2. A detailed breakdown of the costs of ER visits and hospitalizations expected under usual care alone and under SCCMS, which includes the costs of the same-day cardiology clinic, is shown in Table 2. We project that ER visits could potentially be reduced from 200 to approximately 74. We also project a reduction in hospitalizations, from 100 to 70.

    COMPARISON OF COSTS FOR TREATMENT OF ACUTE CORONARY SYNDROMES

    COST OF USUAL CARE ALONE for 200 Patients with Cardiovascular Symptoms

    200 Direct ER Referral by 911 @ $1600

     $320,000

     100 Hospitalized @ $2800

     $280,000

    Total

     $600,000

     

     

    COST OF CARE UNDER SCCMS for 200 Patients with Cardiovascular Symptoms

    20 Direct ER Referral by 911 @ $1600

     $32,000

     10 Hospitalized @ $2800

     $28,000

     10 Discharged from ER

     $ -

    40 Triaged by SCCMS to ER @ $1600

     $64,000

     20 Hospitalized @ $2800

     $56,000

     20 Discharged from ER

     $ -

    100 Triaged by SCCMS to Same Day Cardiology Clinic Visits @ $300

     $30,000

     10 Go to ER from Same Day Cardiology Clinic @ $1600

     $16,000

     10 Hospitalized @ $2800

     $28,000

     30 Hospitalized from Same Day Cardiology Clinic @ $2800

     $84,000

     60 Discharged from ER

     $ -

    40 Advised by SCCMS to Stay at Home

     $ -

     4 Subsequent ER Visits @ $1600

     $6,400

     36 Remain Asymptomatic at Home

     $ -

    Subtotal

     $344,400

     

     

    PROGRAM COSTS of SCCMS

     

     Nurse Care Manager(s) 1.0 FTE

     $135,000

     Computers, SMART Phones, Telephone Charges, etc.

     $15,000

    Subtotal

     $150,000

     

     

    Total

     $494,400

    The elimination of 126 unnecessary ER visits at $1,600 each ($201,600) and of 30 unnecessary hospitalizations at $2,800 each ($84,000) would result in an aggregate cost saving of $285,600. Offsetting this saving is the cost of 100 same-day cardiology clinic visits at $300 each, or $30,000 and the effort of nurse care managers in coordinating same-day cardiology visits, which are not presently a feature of cardiology clinic visits at SHC. Nursing costs are dependent on the maximal "caseload" of patients managed under SCCMS by the nurse care managers. Two nurses, working at a combined effort of approximately 1.5 FTE, could manage as many as 900 patients, This is also the number of patients used to project the rate of ER visits and subsequent hospitalizations among patients enrolled into SCCMS.

    Based on costs applicable at SHC, the total costs of care for all 900 patients receiving usual care alone are approximately $600,000 at the conclusion of one year. Total costs of care for patients receiving ER and hospital care under SCCMS, including the costs of the same-day cardiology clinic visits, are approximately $345,000. Program costs include salary support for nurse care managers, including fringe benefits ($135,000 for 1.0 FTE nursing effort) and the requisite costs of computers, Smart Phones and telephone charges to implement SCCMS on a service basis ($15,000), or a total of approximately $150,000. Under the assumptions and projections presented here, SCCMS would be cost-saving . It must be emphasized that these cost projections reflect a 20% annual rate of ER visits. The actual rate may prove to be substantially higher than this. The staffing level of 1.0 FTE for nurse care managers to provide SCCMS on a service basis allows for expansion of the patient caseload at little or no additional cost.

    Program costs of SCCMS include nursing effort per patient documented by time-logs kept by the computer software, when nurses are "logged-on", and by time-logs kept by nurses during their contact with patients, physicians, and laboratories. The costs of time devoted by SCCMS cardiologists to telephone contact with patients or with nurse care managers are included in program costs. Additional program costs are for communications services and the clinical research database. The latter include computer systems support, provision of interval reports on individual patients and groups of patients for quality control and generation of reports of medical outcomes on individual patients.