Tucked in a nondescript business park in Sacramento, six nurses make and receive calls from hundreds of Mercy patients based in Sacramento and as far away as Woodland, Reno and Redding. All experienced critical care nurses with BSN degrees, the nurses spend their time on the phone assessing, reassuring, coaxing and educating patients, all of whom have been diagnosed with congestive heart failure
|'CHAMP'IONS OF CARE: CHAMP team members Sonia Marrach, BSN, RN (left), Sharon Alfaro, BSN, RN, Leah Talangbayan, BSN, RN, Laura Uro, BSN, RN, and Amy Lasat, BSN, RN, pose with the banner they use to get out the word on heart health. photo by Candy Goulette
The group makes up the Mercy Heart & Vascular Institute Congestive Heart Active Management Program (CHAMP) and it has redefined disease management - and outcomes - for its patients.
In the mid-1990s, Mercy Healthcare, a part of Catholic Healthcare West, hired a full-time medical director of cardiology whose vision was to decompress primary care providers while providing an alternative care environment for CHF patients. The answer was CHAMP, a "virtual clinic" born in 1997 between physician practices and specially trained cardiac nurses, who could provide immediate care for patients with questions or concerns. With standardized protocols, based on where patients are when they enter the program, the nurses are able to assess CHF patients on a routine basis based on information exchanged over the phone.
"Joyce Higley, RD, director of the Mercy Heart & Vascular Institute, said the program is effective because it works to help [primary care physicians] manage long-term care for their patients and reduce the progression in advancement of heart failure.
The model also serves to keep CHF patients out of the hospital and living fuller lives. Nurses work under standardized procedures approved by the medical staff and ordered by the referring physicians. Under these protocols, the nurses adjust medications do assessments and start treatment, all while keeping in contact with both the patient's primary care physician and cardiologists.
As soon as a patient is referred to CHAMP, he or she is assigned to one of the nurses, who then calls to do an initial assessment. Nurses gather information on meds, condition, living situation and dry weight, a important indicator of fluid retention. The initial call is followed up within a week, then again in 2-3 weeks and then monthly to see if the patient is following physician's orders. Patients are encouraged, however, to call in whenever they have questions or concerns. There is no wrong time to call, said Sharon Alfaro, BSN, RN, clinical coordinator of cardiovascular disease management, and often, the call can prevent hospitalization.
"The phone can be a powerful tool," she said. "It connects us to patients forever. Since CHF is not a temporary diagnosis, most of our patients are with us for many years - we've all had patients for a long time. Some call just to get a little reassurance; others wait until they're so short of breath we encourage them to call 911, but we're connected with them in a way you aren't in short, annual office visits."
Alfaro noted each patient is unique - you go forward from where they are.
"Some come into the program with greater illness progression and maintaining the highest quality of life becomes an important factor," she said. "Others are newly diagnosed, with as good a long-term prognosis as you can have with CHF. We work with them to maximize their quality of life."
At the same time, the nurses develop close relationships with their patients. Alfaro noted they've all attended funerals for patients and remain close with surviving spouses.
"It's amazing what you can assess over the phone," noted Sonia Marrach, BSN, RN. "There are some days when I call a patient and can tell something's not right, just by the sound of their voice."
Sometimes, that "something" is depression, a common co-morbid condition with CHF. For that, the CHAMP nurses can turn to an on-staff social worker for assistance.
"When you hear 'heart failure,' you think you're going to die right now," Alfaro said. "We explain this just means the heart is weaker, but they can have a good quality of life if they follow some guidelines we suggest for them. That includes diet, exercise and medication."
"It's education, then reinforcement, reinforcement, reinforcement," Marrach added. "We're detectives over the phone for everything we think we hear. You develop a sixth sense about what's going on in their lives."
Instead of having patients take their blood pressure all the time, the CHAMP nurses use a daily weight as a measure of how well patients are watching their sodium intake and taking their meds. Most are on a cocktail containing a mixture of diuretics, potassium, angiotensin-converting enzyme inhibitors and/or angiotensin receptor blocking agents and beta blockers. Starting with the dry weight established during the patient's first phone consult, nurses can tell how they're doing by watching how steady the weight stays. When it goes up 2-3 pounds in 1 day, that's an indication the meds may need to be adjusted or the diet isn't being followed.