Keeping chronically ill patients out of the ED
Case manager links patients to primary care
When chronically ill patients who have no insurance coverage and no medical home come into the emergency department at Harbor-view Medical Center in Seattle, they are referred for follow-up to a nurse case manager who links the patients to a primary care provider and helps them learn to manage their disease.
In a small sample of patients studied at the beginning of the program, nearly half of the patients referred to case management were connected with a primary care physician and subsequently had low emergency department utilization, according to Daniel Lessler, MD, MHA, associate medical director at Harborview Medical Center and associate professor of medicine at the University of Washington.
"Patients who become established with a primary care provider don't use the emergency department as much and have better outcomes. We are greatly encouraged by the outcomes and we believe that we are really making a difference to these patients," he says.
The program is being funded through Steps to Health King County, part of a nationwide initiative from the Centers for Disease Control and Prevention (CDC) to halt and manage chronic disease.
The initiative was one of several cited when Harborview received the prestigious Foster G. McGaw Prize for Excellence in Community Service. Each year, the $100,000 prize is presented to a health care organization that provides innovative programs that significantly improve the health and well-being of the community.
Other programs for which Harborview was recognized include satellite clinics in downtown Seattle for the homeless and uninsured; supported housing and unemployment programs for the mentally ill; community house calls by bilingual and bicultural caseworkers to the immigrant population; and the Injury Free Coalition for Kids of Seattle, a partnership to promote the safety of children in inner-city and immigrant communities.
Like other safety net hospitals, Harborview Medical Center has an overcrowded ED and faces an epidemic of diabetes and high utilization rates by people who use the ED for primary care.
"An emergency department visit is a sentinel event that should not happen with asthma and diabetes. We knew that we needed to be making more of an effort to connect the underserved and vulnerable population to primary care," Lessler says.
The ED refers patients who have a diagnosis of diabetes or asthma and who do not have a primary care provider to Audrey Paisley, RN, diabetes and asthma nurse case manager. She follows a disease management algorithm and is backed by Lessler and a nurse practitioner who help when questions arise.
Once patients are identified as eligible for the program, Paisley attempts to find them through telephone calls, letters, and assistance from homeless shelter staff and nurses. She typically carries a caseload of 90-100 patients.
"Many of these patients speak English as a second language. Some have cell phones. Some have no telephone. Some are literally living under bridges. Others are in shelters. I have the most success with patients who have cell phones and who want to be engaged in managing their health," Paisley reports.
Upon initial contact, she conducts a questionnaire; addresses any urgent financial, medical, and psychosocial needs; and identifies barriers to self-care. Then she develops a care coordination plan, makes a primary care appointment at a clinic, and mails educational materials to the patient and/or schedules the patient for classes.
Paisley works with the patients to establish a relationship with a primary care provider in the area in which they live, whether it is a community clinic that provides free or discounted services or one of Harborview's clinics. For instance, some of the patients who are newly arrived immigrants may receive primary care in the hospital's international medicine clinic.
"Many of the patients come as far as 30 miles for treatment. The ultimate goal is to find a community clinic close to where the patient lives or get them an appointment at one of Harborview's clinics," Lessler says.
The goal of the program is to ensure that patients are established with a primary care physician, to get them connected to a program that offers free or reduced care, and to keep patients with chronic diseases out of the emergency department when their needs can be met by a primary care provider, Paisley says.
Paisley helps eligible patients get signed up for community resources such as Medicaid, the hospital's charity care, the Department of Social and Health Services' programs, and the hospital's low-income allowances program in which low-income patients pay only a portion of the bill.
She sets an appointment with a primary care provider and follows up with a letter with a reminder of their appointment, a lab referral form, and directions to the lab and clinic.
"When I initially talk to them, most patients have just been diagnosed and it's very difficult to engage them in any form of education. The majority of questions these patients have are about financial issues and transportation to the hospital," Paisley says.
The initial call
During the initial call, Paisley helps the patient get set up with a financial counselor, determines other consultations that may be needed, and makes sure the patient is taking his or her medicine as prescribed.
"In the early stages, one of my main goals is to assure that the patient's medical care is covered so they won't worry about getting a bill. If they get a lot of bills, they tend to stop coming and end up back in the emergency department," she says.
Paisley then sets up a meeting with a nutritionist for newly diagnosed diabetics and provides information on classes on diabetes or asthma offered in the hospital's Patient and Family Resource Center.
After the first few conversations, she begins to address self-management issues, such as blood glucose monitoring for diabetics and peak flow monitors for people with asthma.
"I contact them every two weeks. Once they are settled into the routine and doing self-monitoring, I work with them to set goals and determine strategies to help them meet the goals," Paisley says.
During the follow-up calls, Paisley educates the patients about following nutritional guidelines in their diets, getting regular exercise, and following other aspects of their care management plan, such as not smoking.
During each conversation, she stresses the importance of medication compliance. For instance, with asthmatics, she explains the benefits of using the controller medicine regularly instead of relying on their rescue medicine.
Before she calls the patients, Paisley accesses their medical records and reviews the laboratory values and other results from the last primary care appointment. She determines when their last medication prescription has been filled, and if it hasn't been filled for a while, discusses it with the patient, and finds out what barriers need to be overcome.
Paisley also checks the status of the patient's funding application and whether the paperwork needs to be updated or reviewed.
If patients fail to show up for an appointment or call to cancel an appointment, Paisley follows up to find out what barriers are interfering with compliance. If transportation is an issue, she can refer them to programs that provide reduced bus or free cab fare for eligible patients.
Paisley follows up with the patients on a regular basis for about six months on average.
"Some are fairly educated and able to keep track of their appointments and their medication regimen, and I can close those cases within two to three months. I follow some for a year, primarily because they don't understand the system; they don't know how to arrange transportation or order medication refills," she says.
Paisley gives patients a reminder call the day before they have an appointment. Before she releases them from the program, she stops calling to see if they will still remember the appointment.
"If they don't show up for the appointment without a reminder, it tells me they need a little more case management. It's a little test to see if they're ready to go out on their own," she says.
If her patients have another emergency department visit, Paisley is notified and immediately follows up.
One of Paisley's biggest challenges is to educate patients about how the health care system works.
"Many of the patients have low literacy. They don't speak English well and are afraid to share personal information about themselves, which they have to do when they apply for pharmacy benefits. They simply do not understand the health care system," she says.
Some patients don't understand that they need to show up for their primary care appointments on time or that they can't just walk in to a clinic and demand to be seen. Some need help with tasks as simple as calling the pharmacy refill line to reorder medications.
"I ask my patients to call me if they think they need to go to the emergency department. I might be able to get them a walk-in appointment with their clinic or help them get their medication refilled if they don't understand how. I work with them to keep them out of the emergency department," she says.
Very few patients in the program who make regular visits to a primary care physician go back to the emergency department, Paisley reports.
"A few asthma patients have gone back but it's because of language differences and their lack of understanding of how the medication works," she says.
(Editor's note: For more information, contact Audrey Paisley, RN, diabetes and asthma nurse case manager, Harborview Medical Center, e-mail: [email protected].)
When chronically ill patients who have no insurance coverage and no medical home come into the emergency department at Harbor-view Medical Center in Seattle, they are referred for follow-up to a nurse case manager who links the patients to a primary care provider and helps them learn to manage their disease.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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