With its team of nurse care coordinators across Primary Care, BWH’s integrated Care Management Program (iCMP) has been providing personalized care and attention to some of the hospital’s most high-risk patients for more than five years. A large subset of these patients suffers from chronic heart failure—the most common cause of iCMP patients’ hospital admission.
Helping these patients to stay well is a privilege, says Mary Chalifoux-Conley, RN. She co-manages 71 iCMP heart failure patients alongside practice-based nurse care coordinators, with the goal of improving their care and reducing inpatient admissions through coaching and intensive disease management. The team also collaborates with BWH primary care physicians (PCP), cardiologists, heart failure nurse practitioners and palliative care specialists.
“I assess patients’ understanding of their diet and their medications,” said Chalifoux-Conley. “I help them navigate the health care system, engage their families in their care and support behavioral changes aimed at improving their health.”
She also frequently communicates with her patients’ PCPs and cardiologists, providing them with status updates or changes in vital signs, to determine if adjustments to medications or dietary restrictions are needed.
If patients are admitted to BWH, Chalifoux-Conley makes a point to visit them. She says it is important that these patients understand the role she plays in their care—especially if they are new to the Brigham—and how to find her. When they are ready for discharge, she strives to make their transition home as seamless as possible.
“Mary has been able to engage many high-risk patients in their own care, help them improve their health and prevent them from needing to be admitted to the hospital,” said Lisa Wichmann, RN, iCMP nursing director. “Everyone’s experience with Mary has been very positive.”
One of many beneficiaries of Chalifoux-Conley’s care is James Ackerman, a semi-retired professor who recently celebrated his 96th birthday. In the past year, Chalifoux-Conley has coordinated Ackerman’s home care, followed up with him on important test results and remained in touch with his PCP and cardiologist every step of the way.
Ackerman’s wife, Jill Slosburg-Ackerman, said, “I am so grateful to the staff at the Brigham for the amazing care that our family receives. I had no idea there would be this kind of support for my husband. Mary has an ability to balance the science and medical issues with humanity. It’s more than just the medicine; Mary has made it easier for all of us.”
When needed, Chalifoux-Conley refers patients to BWH’s Ambulatory Cardiac Triage Intervention and Education (ACTIVE) Unit, a multi-disciplinary outpatient cardiology infusion center led by advanced heart disease nurse practitioners. In the ACTIVE Unit, patients can receive intravenous diuretics as needed, as well as pharmacist-led medication reconciliation, and education and assessment by a nurse practitioner. As an ambulatory treatment alternative to a hospital admission, the unit has become a successful option for patients with worsening heart failure symptoms. To date, Chalifoux-Conley has referred 18 patients to the ACTIVE Unit for the most specialized care.
Chalifoux-Conley and her colleagues believe that the future of iCMP and heart failure outreach lies in preventive care. Rebecca Cunningham, MD, iCMP medical director, says there is a cohort of patients Chalifoux-Conley is not yet seeing who could benefit from earlier intervention and additional self-management tools.
“I think there’s a lot more we can do to educate patients,” said Chalifoux-Conley. “It’s the 40- to 50-year-olds who may all of a sudden start to see a rise in their blood pressure or lipids. We need to educate them more quickly about nutrition, and if they’re pre-diabetic, get them on the right medications and help them learn how to manage their health.”