CM interventions prevent readmissions, ED visits
Nurses meet with at-risk patients
Group Health Cooperative's case managers target patients with complex medical conditions and/or psychosocial issues who have been hospitalized and work with them on managing their health with a goal of avoiding admissions, readmissions, and emergency department visits.
• At-risk patients are identified using a combination of patient diagnoses, their conditions, and psychosocial situations to determine who is at risk.
• Hospitalists and case managers embedded in high-volume hospitals provide care and care coordination for patients covered by the health plan.
• Case managers call patients after discharge and refer those with long-term needs to the health plan's case managers for follow up.
Group Health Cooperative’s program that provides case management for patients with complex conditions and/or psychosocial issues has decreased preventable admissions, readmissions and emergency department visits, particularly among the Medicaid population, says Barbara Wood, BSN, MBA, executive director of case management for the Seattle-based non-profit health system.
Group Health Cooperative is an integrative healthcare system that includes a health plan, 25 clinics, six specialty clinics, seven behavioral health clinics, and a small hospital.
The organization established the Emergency Department and Hospital Inpatient Improvement project in 2009 with a goal of improving care transitions. Since then, the organization has reviewed the process, looking for ways to make improvements and further reduce admissions, readmissions, and emergency department visits, Wood says.
Group Health Cooperative partners with hospitals throughout the state of Washington to coordinate patient care and ensure smooth transitions. The organization has embedded hospitalists and nurse case managers, called case management liaison nurses, to manage care for patients covered by its health plan in the six highest-volume hospitals and provides telephonic care coordination for patients in other hospitals.
"We contract with community hospitals to provide care for all of the patients in our health plan. As part of our contract with the high-volume facilities, our hospitalists treat the patients covered by our health plan and our case management liaison nurses are responsible for utilization management, discharge planning, and transition management for those patients," Wood says.
A team of clinicians, including Group Health hospitalists, analyzed why patients were readmitted or visited the emergency department after discharge and developed a standardized tool that rates patient acuity to help determine who is at risk, she says.
"We now are using a combination of patient diagnoses, their conditions, and psychosocial situations to determine who is at risk," Wood says. For instance, someone with diabetes wouldn’t necessarily be at risk, but if the patient is unstable or frail or has no support system at home, that would stratify him as high risk. "Patients on certain drugs, such as warfarin, are also high risk," she says.
After research, the team determined that high-acuity patients should have a follow-up visit with a primary care physician within seven days of discharge and that patients who are low or medium risk should see their physician within 14 days. "When we looked at our records, we realized that many patients were waiting much longer than 14 days to see their physician after a hospital stay. We want to get them in as quickly as possible, particularly if they are at high risk," she says.
If patients are high risk, the nurse or an administrative assistant makes the appointment while they are still in the hospital. "Our goal is to get the appointment made, no matter who does it. Typically the nurse explains the need for the follow-up appointment to the patient and family and the administrative assistant makes the appointment," Wood says.
Every morning, the embedded case management liaison nurses get a census of Group Health patients in the hospital and review their medical records. Early in the day, the Group Health hospitalists and case management liaison nurses meet to review all the patients and determine which patients are high, medium, or low acuity. They also discuss potential discharge needs, and any psychosocial issues the patients may have that could affect the discharge. "As the patient gets closer to discharge, the team starts talking about what the patient wants and what the clinicians think is reasonable and formulating a discharge plan," she says.
On an ideal day, the case management liaison nurse sees all of the Group Health patients in person, Wood says. If that’s not possible, they visit the high-acuity patients, discuss their condition and treatment plan, and what is likely to happen next during their course of treatment. In some cases, they talk with the patients about their benefits and what their plan will cover. For instance, if a patient is going to be discharged to a skilled nursing facility, the nurse will let the patient and family know how many benefit days are left in the benefit period.
The nurses and physicians make sure the patient and family members understand why the patient is in the hospital and educate them about the disease and what they will need to do to manage at home after discharge. They discuss their medications, how and when to take them, and the importance of following their medication regimen and treatment plan. They also educate the patient on what signs and symptoms indicate they should call the doctor. In addition to verbal teaching, they give the patients and family members the same information in written form.
The nurses see patients with moderate acuity at least once while they are in the hospital and stress the importance of making a follow-up visit with their primary care physician.
The program’s goal is for all patients covered by Group Health insurance, regardless of acuity, to receive a follow-up call within 24 to 48 hours after discharge.
The case management liaison nurses call the patients that have been discharged from the hospital in which they are embedded. Patients who are treated in Group Health clinics are called by complex care managers who are embedded in Group Health’s clinics. Other health plan case managers call the other patients.
All of the case managers, regardless of where they are located, use the same tools, the same language, and the same documentation.
During the calls, the nurses conduct an assessment to make sure the patients understand their chronic disease and its potential impact on their lives, if they are following their plan of care, and if they have questions and concerns. If the patients didn’t leave the hospital with a follow-up appointment, the nurse finds whether they have made an appointment. If the patient hasn’t made an appointment and plans to see a provider in a Group Health clinic, the nurse sets up the appointment while the patient is on the phone.
"The nurses check on the patients’ conditions, support systems, and assess the transition to determine if patients need extra follow-up," she says. They look for any barriers that may interfere with the patient following the treatment plan or receiving follow-up care. For instance, if patients are not taking medication because of financial issues or need transportation assistance, the nurses call in a social worker for assistance. They also call in the social worker if they determine that patients need resources such as meal deliveries or household help.
"Sometimes, patients just need a lot of education on their conditions and the importance of following the treatment plan. If they are not absorbing their plan of care or are resistant to treatment, the nurses will bring them into case management and work with them. It’s much better to help them get control of their health in the beginning, rather than waiting until they are higher-acuity patients," she says.
If patients don’t have a plan of care or aren’t adherent, the case manager may refer them to complex case management, where the nurses will follow them for 90 to 120 days and give them the tools to be successful with their plan of care, she says.
"Patients may not be successful because of lack of knowledge. The nurses talk about why it’s important to have a plan of care, the importance of following it, and what patients should do if they don’t feel well.
The organization has a home health residential care program in the Puget Sound area that provides in-home services to patients who are homebound or need a lot of support. In addition, Group Health contracts with an organization that provides support for at-risk patients from nurse practitioners throughout the state.
"Now we are working on strategies to make sure patients who are hospitalized meet medical necessity criteria and finding alternatives to social admissions," she says.
For instance, Group Health’s on-site hospitalists consult with the emergency department staff at their hospital to evaluate patients’ symptoms and medical history to determine if they meet hospital admission criteria. n
