Embedded CMs work with physicians, hospital
Embedded CMs work with physicians, hospital
Goal is to improve care, reduce readmissions
As part of its efforts to reduce admissions and emergency department visits, Capital District Physician Health Plan (CDPHP) has embedded case managers in 15 primary care practices and is conducting a pilot project that embeds a case manager in a local hospital.
“Communication between the health plan and providers is the key to improving patient care and preventing readmissions. We are working to exchange information with the hospital and the physician practices. Most of the time, none of us has the whole patient story because we don’t know what the patient isn’t telling us,” says Charlene Schlude, RN, CCM, director of case management for the Albany, NY-based not-for-profit health plan. The health plan started its initiative in 2010 with a pilot project in which case managers were embedded in three practices. The program has been expanded into other practices with a high number of CDPHP members who are chronically ill, Schlude says. “We decided to expand based on the initial evaluation of the costs of the case managers compared to the reduction in admissions and emergency department utilization,” she says.
The embedded case management program is part of CDPHP’s Enhanced Primary Care initiative, a patient-centered medical home model that works directly with physicians and staff to provide care coordination. Large practices that care for a large number of patients with significant healthcare needs are offered the embedded case managers. The health plan also provides telephonic case management for high-risk patients in the smaller practices.
The embedded case managers partner with the physicians to determine which patients would benefit from case management and address their needs. “The patients targeted for this program are the most chronically ill ones who consume a good portion of healthcare dollars,” she says.
Typically the embedded CDPHP case manager gets a list of patients coming into the practice that week and determines which ones need to be seen. They meet with patients who come into the office and follow up by telephone. “The goal of the program is to assist physicians to educate patients on the importance of their treatment plan and to identify any barriers to adherence. That’s where the embedded case managers can help, by taking time to look at each individual patient and his or her needs,” Schlude adds.
The embedded case managers have private office space where they meet with patients. They follow up by telephone or during the patient’s next visit. They always offer patients the option to come in and talk to them when they don’t have a primary care provider visit.
“The case managers take a lot of time with the patients and often uncover problems such as financial and social issues that can interfere with patients following their treatment plans,” she says.
The health plan has refined its model over the years as the nurses have developed a better understanding of what patients they need to see and how to collaborate with the medical office staff. “We recognized what really works and what patients and physicians feel is valuable,” she says.
Case managers are in the large practices every day and the smaller practices a few days a week. They can call on support from health plan social workers who visit patients at the primary care offices on a case-by-case basis. For instance, they work face-to-face with Medicaid managed care beneficiaries who have a lot of social needs. Some are in shelters and the social workers try to find them lodging. Many have lost their medication.
Some patients have been followed by the embedded case manager for a year or longer. Others just need help for a short period of time to get their disease under control.
The health plan also has embedded a nurse case manager at a large medical center that provides care for a large number of CDPHP members. The case manager visits CDPHP members with chronic illnesses before they are discharged, explains the care management process and how it can benefit the patient, and sets up a primary care visit within seven days of discharge.
“Readmissions are on everybody’s mind these days. Hospitals are being challenged with readmission penalties, and it’s beneficial for them to partner with health plans instead of doing their thing while we do ours,” she says.
The case manager on site has access to the hospital’s electronic medical record and reviews the records of members who have been admitted to determine if they are appropriate for follow up. “Often patients will be in the hospital for a procedure such as a joint replacement but the case manager will determine from the medical record that he has heart failure, diabetes, or another chronic condition,” she says.
If the case manager at the hospital identifies a patient with a chronic condition, she will refer the patient to the readmission avoidance case manager, who follows up on Days 7, 14, 21, and 28 after discharge.
The case manager in the hospital visits patients who are appropriate for case management at the bedside and identifies social concerns and other information that might not show up in the chart and shares the information with the embedded case manager or the telephonic case manager. “Patients go home much quicker today, and this way we can identify situations and issues that might send them back to the hospital,” she says. For instance, a patient might live alone or have had frequent falls, and a discharge to home might not be the best option.
“This is another level of how we support our enhanced primary care practices. We let the physician know that their patients have been in the hospital and that we are going to follow them for 30 days to make sure the transition goes smoothly,” she says.
Visiting patients in person helps engage them in the case management process after discharge, Schlude says. “We have learned from the embedded case management model that patients are more receptive when they see the case manager face to face rather than getting a phone call,” she says. The embedded case manager typically sees the patients a couple of times before discharge and prepares them for the follow-up phone call, she says. The case manager determines if the patient has financial concerns or needs community services. She discusses the medication regimen and tries to get a feel for whether they can afford to purchase them or pay their co-pay and contacts the physician when appropriate to see if a less expensive medication would be as effective.
“We take a lot of time trying to determine what might interfere with a safe and effective discharge. We know that if patients can’t afford their medication, they choose not to fill the prescription or to omit one. The goal of our embedded case management programs is to help patients maximize their health and improve their quality of life,” she says.
As part of its efforts to reduce admissions and emergency department visits, Capital District Physician Health Plan (CDPHP) has embedded case managers in 15 primary care practices and is conducting a pilot project that embeds a case manager in a local hospital.
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