CM helps high-risk members avoid hospitalizations
Initiative reduces cost, improves members' health
Face-to-face case management for members at high risk for health care exacerbations has paid off for Great-West Healthcare, a Greenwood Village, CO, health plan that serves as a third-party administrator for about 6,000 self-insured employer groups.
In about 50% of Great West's markets, eligible patients in the health plan's end-stage renal disease program and the neonatal intensive care program meet face to face with case managers who go on-site to the hospital or to members' homes.
Case managers in the health plan's end-stage renal disease program work with members at home or in the dialysis center, helping them stick to their diet and plan of care. The neonatal ICU program places case managers in the NICU where they collaborate with the physicians and nurses on the plan of care and ensure that the parents have the skills they need to care for their newborn after discharge.
Since the case management program began, hospitalization rates for end-stage renal disease patients have decreased by 10% to 14%.
The neonatal ICU program has shown a 32% reduction in readmissions for premature infants and generated a three to 5.5 return on investment for the program.
Great-West contracts for the NICU case management program through an outside vendor. The high-risk pregnancy program is provided by another vendor but they are linked together through the data feeds and through the health plan's care management system.
"The programs provided by our vendor partners are completely branded for Great-West Healthcare. The vendors all feed information into our system or use our software system so we can ensure that our members receive continuity of care and no one falls through the cracks," Norris says.
When the health plan is notified that a member has delivered a baby prematurely, it triggers a referral to the on-site case manager who goes to the hospital's neonatal intensive care unit and goes over the chart with the physician who is managing the infant's care.
The health plan has arrangements with the hospitals to have the nurse case managers come to the unit and review the cases.
"They work very closely with the NICU nurses and physicians. Having another pair of eyes looking at the chart and the child's condition is very beneficial to the baby," Norris says.
If the mother is still in the hospital, the case manager meets with her at the same time.
"The case managers make it a point to meet with the family to discuss what is taking place and go to the family's house if necessary. We want to help the family understand the child's condition, and the discharge plan," Norris says.
The neonatal case manager visits the NICU and reviews the chart weekly, working with the doctors and nurses to make sure that the infant gets the appropriate level of care that meets their needs.
"Some of these infants have very intensive needs and requirements for care and others are in the NICU only a few days before discharge and could receive a lower level of care. We work with the doctors and nurses to make sure that the level of care the baby receives is based on the severity of his or her condition," Norris says.
They stay in touch with the family, keeping them apprised of what is going on and when they can expect the infant to be discharged to home.
"The biggest piece of our on-site neonatal case management program is to make sure that the parents receive the education they need to be able to take care of the baby at home," he says.
When a premature infant is scheduled for discharge, the case manager verifies that the baby meets the required outcomes for going home.
They educate the family on the plan of care, teach them how to use the equipment and monitors that will accompany the baby home, and reassure them that they will receive the support they need when the baby is home.
"We want to make sure the family knows how to take care of the baby. If the infant is on a nebulizer or a ventilator, we make sure that they understand how it works and what they need to do," he says.
Once the baby is discharged, the case manager follows up with the family to make sure they are following the plan of care and educates them about when they should call the doctor or take the baby to the emergency room.
For instance, infants often get a stomach ache or vomit when they are being transitioned to oral feedings. If the family takes a baby who has been in the NICU to the emergency department, the baby almost always will be readmitted to the NICU as a cautionary measure.
"We want to educate the family about what is normal and what is not so they can avoid unnecessary trips to the emergency room and hospitalizations," he says.
The family also has around-the-clock access to the health plan's nurse line in case they have questions or concerns.
Many of the members in the NICU program are identified through Great-West's high-risk maternity program, a telephonic program in which case managers follow members at risk for complications of pregnancy or premature births through the pregnancy and work with the members' physicians to ensure that they receive the care they need.
When claims data or referrals identify a member as being pregnant, she receives an outreach call from a case manager who conducts multiple assessments to determine the risk.
The high-risk maternity case managers follow up with women who are at risk for complications of pregnancy on a regular basis and work with the members' physicians to make sure their needs are being met.
Members are referred to the end-stage renal disease program when they are in active dialysis.
When a case manager receives a referral, she contacts the members' physician for information about the patient's condition, meets with the patient in their home, at the dialysis center or the nephrologist office and conducts an extensive assessment to find out where the case management focus should be.
The assessment includes questions about the members' home life, living conditions, and personal life.
"We make sure that the patient's home environment and family support would facilitate them being able to complete the dialysis process. We make sure the family can handle getting the patient to the dialysis center and assist the family in communicating with the physician," he says.
The case managers help the members stick with their physician's dietary recommendations and teach them how to keep their dialysis access point clean.
"The majority of hospitalizations for these patients are due to infection of the access point for dialysis. By educating the members and working with them on the correct type of access, we have been able to reduce hospitalizations quite dramatically," he says.
The case managers reinforce the physician's recommendations for a diet and exercise regimen.
"We fill the space in between the doctor visits, following up to make sure they are following the treatment plan," he says.
The case manager contacts the member every other week on average, depending on the member's needs and availability.
If the members have comorbidities, such as diabetes or congestive heart failure, the renal disease case manager coordinates the care for those conditions.
"All our programs follow a primary nurse model. One case manager works with the member as much as is possible," Norris says.
Face-to-face case management for members at high risk for health care exacerbations has paid off for Great-West Healthcare, a Greenwood Village, CO, health plan that serves as a third-party administrator for about 6,000 self-insured employer groups.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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