Disease Management Wins Drive Essentia Toward ACO

With all the negative chatter about accountable care organizations from healthcare leaders and in public comment forums, it is interesting to see which healthcare systems are ready to leap at the chance to initiate ACOs.

Often the ones at the head of the pack are the ones who feel their current systems are so locked in and on target, that they seemingly can't wait to get started.  

The Essentia Health System in Duluth, MN seems to have that attitude. Essentia is getting ready to transition to an ACO after receiving data showing the effectiveness of its disease management program. While national heart failure readmission rates are  about 40 to 50% range, the sickest heart failure patients in Essentia's program have admission rates between 0 and 2%, says Linda Wick, NP, RN, manager of the Essentia Health System's heart failure program, formerly known as St. Mary's Duluth Clinic Heart Failure Program.

Readmission rates were estimated at 3% to 7%.

One of the most significant aspects of care that the system does, and does successfully, is disease management, working with the patients, tying that in with a telemonitoring scale program linked to patients with cardiovascular conditions, says Wick.

"Disease management is the thing," she says. "I think a lot of people don't fully understand what that means. We look at patients with the understanding we are responsible for them 24/7," Wick said.

She is a nurse, and from that perspective Wick says the nurses have guided the process of the disease management program, especially in ensuring follow-up care. "We are giving patients the skills and resources they need to manage their own disease, and they know we are available," she explained.

Under the program, the hospital has reduced 911 calls and admittances to the emergency departments, as well as showing hefty savings, she said. An Essentia Health study with Blue Cross Blue Shield of Minnesota revealed $1.25 million in healthcare savings for evaluation of 29 patients over a six-month period, according to Wick.

Essentia has established what she terms a true team, of nurses and physicians, overcoming the fact, she says, that physicians, generally, have not been adept at disease management. In the healthcare reform era, that is something that physicians must continue to work on, she says.

"I'm not picking on physicians, but they haven't really been trained in disease management," Wick said. Not all physicians are fuzzy with disease management. "Primary care docs, they get it, they totally get it," she explained. The particular area of concern in developing disease management programs with physicians involves the specialty physicians, such as cardiologists.

Disease management is all about keeping tabs with patients who may lose their way. For instance, as Wick says, patients' doctors may have taken away their salt shakers, and that is all well and good, but deep down, patients are still having a problem with sodium intake. "They still may have that chicken sandwich at McDonald's and they think it's OK, but it's loaded with salt," she says. "That piece of disease management, discussing that, is something nurses are trained to do."

Referring to the subspecialties who sometimes stumble at disease management, Wick says, "I

"I think cardiologists are trained as procedurists and it's harder for them to understand disease management," she says.

To augment its system, the hospital uses a telemonitoring scale system, in which a patient sets up a scale in his or her home, which takes their weight, for instance, and that information is linked into the hospital. The system poses questions about the patient's health and it is something that the patient is supposed to step on every day. Information is transmitted to a cardiac nurse, who can make adjustments if necessary, based on medication, and track the patient's condition.

When the hospital initiated its program using the telemonitoring scale, and consistent follow-up care of patients, some physicians were concerned that they were going to be caught up in the details of follow-up care that would interfere with all their other work.

"If you are dealing with all these patients, we are going to get all these calls,''' Wick recalls physicians telling the nursing staff.

Hospital officials also were concerned about an anticipated overflow of the emergency department patients, especially among those who have had debilitating cardiac conditions, and whether the telemonitoring scale system would actually make them more nervous. She acknowledged that the telemonitoring scale system, generally, across the nation, has had mixed results. For Essentia, however, it's working, Wick says.

The hospital system's disease management process has put a lid on calls of anxiety from patients and visits to the Emergency Department, Wick says. "The 'calls' aren't there, because they are well managed," she says of the patients. "They are well managed and they don't call," she says. "The onus is on us to partner with our patient. How we manage this so it's not a crisis, it's about preventing a crisis.

About 200 of 1,200 patients in the healthcare system's cardiac program are involved in the telemonitoring scale program, she says. The hospital ensured only those who really need the extra support of the scale would be part of that process, she says. Indeed, the hospital receives no reimbursement for the scale, which is estimated to be part of an overall $10,000 telemonitoring cost for each patient, she says.

"In our philosophy of preventing crisis, we're seeing people on a regular basis and managing them; sometimes it's a phone call and sometimes it's patients seen at a clinic, but that's really where our success lies," Wick says. "The scales are important tools. Everybody loves technology but you have to target the resources appropriately," Wick says.

As Essentia moves forward, it is formulating an ACO plan. "Everything we do in our program fits in the current definition of ACO," she says. "I love it, it works and it's patient centered and you are paying us for the right thing. Now we are paid for failure if I don't manage these patients well. That's not the right thing for the patient and the patient is suffering."

What Essentia is doing with disease management and its telemedicine scaling program has attracted the attention of the Healthcare Innovations Exchange,

part of the Agency for Healthcare Research and Quality. In May, AHRQ invited Wick to display the health system's concepts at its headquarters in Rockville, MD.

The concept has proven to help patients and reduce costs, Wick says. "We are a team and we are winning."