High-risk management crosses disease, age lines
High-risk management crosses disease, age lines
Even skeptics become evangelistic’ over outcomes
Two years ago, the Lahey Clinic in Burlington, MA, launched a high-risk population management initiative to improve the health of its most frail and chronically ill patients. It was a proactive response to "the health system challenge," explains Jerry C. Maliot, MD, MS, Lahey’s medical director for utilization management. Part of that challenge for any health system, he says, is taking care of the 0.5% to 1% of patients who account for 20% to 30% of all medical costs.
The clinic already had several disease management programs for conditions including asthma, depression, and anticoagulation management. "But we wanted a program to take out to the ambulatory clinics," Maliot notes. The Lahey system comprises 300 specialists at the Lahey Clinic as well as 150 internists, family practitioners, and pediatricians in the Lahey Community Practice Network, scattered throughout eastern Massachusetts.
The proposed systemwide program had to meet four stiff criteria:
1. Implement program rapidly.
2. Show results within 12 to 14 months.
3. Quickly engage physicians throughout the system.
4. Demonstrate to Lahey’s Community Practice Network physicians the value of association with the Lahey system.
After exploratory discussions, the consensus was to partner with StatusOne, a Hopkinton, MA, consulting group that is skilled in the identification and management of high-risk patients. The approach worked. "Some of the most skeptical doctors became positively evangelistic when they saw how the involvement of a case manager could help them bring problem patients under better management," Maliot reports. Within the first year, patients’ functional status improved 16% according to SF-36 questionnaire results. (For additional outcomes, see charts, p. 115. For more on the SF-36 questionnaire, see information box, p. 116.)
Unlike many disease management programs, Lahey’s selects patients according to risk, not diagnosis. Psychosocial interventions are as common as clinical interventions because emotional issues are typically associated with severe chronic or acute illnesses. Counseling for increased reliance on self and community support systems is stressed. Outcomes are measured in functional and medical terms. High-risk caseloads have a turnover rate of 12% to 15% a month due to improvement, death, or change in physicians.
Lahey began its partnership with StatusOne in May 1998. During the following months, Maliot and colleagues worked with the consultants to complete the essential milestones:
• June: Rolled out plan to medical directors throughout network.
• July: Hired eight case managers.
• August: Introduced assigned case manager and high-risk patient management software to each of Lahey’s 24 sites.
• September to December: Refined technical and communication processes.
The case managers are nurses with backgrounds including utilization review for insurance plans and home care. One has experience in pediatrics as well as adult medical/surgical services. Each manager covers several physician groups. They started with panels of 75-85 patients.
One improvement, currently under consideration, is a shift from regional to central offices, giving the case managers more phone contact, with face-to-face contact as needed. "We’ve learned that most of the needs can be addressed telephonically, and this change could enable us to cast our net a little more broadly to about 100 patients per manager," Maliot says. "But still, there will be a handful who become very attached and call their case managers often. That’s to be expected. We consider it a legitimate psychosocial intervention. The extra support can improve their sense of well-being and functional status. It could perhaps save hospital admissions and emergency room visits, as well."
When asked why the program works so well, Maliot says, "I can’t stress enough that quality management and utilization management are one and the same." With cohesive treatment plans and a holistic range of services, patients function better and use health care services more appropriately. For example, a case manager might help a patient complete unfinished business with an estranged spouse or adult child. Or a patient might become more involved in family and social activities after getting hearing aids.
Strong buy-in from the top medical leadership sets the stage for acceptance throughout the system. Physicians’ awareness of the program is reinforced by monthly "impact case" reports. These one-page briefs showcase achievements by describing a high-risk patient, how the case was identified, interventions, and outcomes. The doctors are delighted when patients from their own panels or from their group practices are featured as success stories. (For excerpts from two impact case reports, see story, at right.)
Lahey’s organizational structure breeds cohesiveness. "The physicians are all linked at the bottom line," says Maliot, "so when one wins, every-
one wins." Because commitment to teamwork is part of the culture, incorporating case managers into ambulatory care practices wasn’t entirely
foreign. Nonetheless, the managers’ personal attributes and skills were crucial, he adds. "We wanted people who are smart and have a sense of humor and adventure because our approach is different than the typical disease-specific model."
The decision to partner with a specialized and experienced consulting group jump-started the project. "If we had appointed a study committee and done all the standard brainstorming," he says, "we’d still be talking about it."
The case management project moved from talk to impressive results in little over a year:
• Admissions are down 28%.
• The cost per case-managed member per month is down 28%.
• Functional health status is up 17%.
Need More Information?
For more information about selection and management of high-risk patients, contact:
- Jerry C. Maliot, MD, MS, Medical Director for Utilization Management, Lahey Clinic, Burlington, MA. E-mail: [email protected]
- StatusOne, 85 Main St., Hopkinton, MA 01748. Telephone: (508) 497-9395. E-mail: [email protected].
For more information about measuring functional level with the SF-36 questionnaire, contact:
- Medical Outcomes Trust, PMB 503, 198 Tremont St., Boston, MA 02116-4705. Tele-phone: (617) 426-4046. Web sites: www.outcomes-trust.org and www.sf-36.com.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.