CMS through the continuum help keep patients healthy
Organization provides seamless continuity of care
A comprehensive case management program at Desert Oasis Healthcare that provides care coordination for patients throughout the continuum keeps patients healthier and out of the hospital. And it's cost effective.
"Our belief is that excellent patient care is also the most cost-effective care. We try to fill all the gaps in the health care system and give patients the support they need to stay healthy and out of the hospital," says LaDonna Headley, RN, director of case management for the IPA and medical group.
The case management program at Desert Oasis Healthcare has multiple components that work hand in hand to provide continuity of care for patients along the continuum, Headley says.
"We have different programs to take care of a patient's needs throughout the continuum of care. They can go from one program to another or be in multiple programs simultaneously, if needed," Headley adds.
Desert Oasis Healthcare is a team of primary care physicians and ancillary providers. The organization has headquarters in Palm Springs, CA, with offices located throughout the Coachella Valley area. The medical group is a full-risk provider with most of the health plans.
The Desert Oasis physician group provides care for about 22,000 seniors enrolled in Medicare Advantage and a total of 78,000 patients. The 30-day readmission rate for Medicare Advantage patients enrolled in Desert Oasis is between 11% and 12%, Headley says. This compares to an average of 19.6% readmitted within 30 days for traditional Medicare beneficiaries, according to a study in the April 2, 2009, issue of the New England Journal of Medicine.
Case managers who are employed by Desert Oasis work in local hospitals and nursing homes to ensure that patients get the care they need in a timely manner. Intensive case managers coordinate follow-up care for patients with complex needs and multiple comorbidities. Case managers follow up with patients who have been discharged from the hospital or the emergency department.
Desert Oasis' Living and Aging Well program provides an array of services for seniors, including in-home physician visits for homebound patients, disease management for chronic diseases, and health education programs.
In addition, Desert Oasis provides case managers on call around the clock so that if a patient or a physician calls, he or she always speaks to a live person.
"We're always looking at better ways to serve our patients. We want to be the GPS for our patients to help them navigate the health care system and to provide care that is coordinated and timely," Headley says.
The case managers call any patients who made an emergency department visit and those who are discharged from the hospital within 24 hours to ensure that they get follow up.
In addition, when patients make an emergency department visit or are admitted to the hospital, the case management team analyzes each case to determine what, if anything, could have been done to give them the service and medical care they needed to prevent the admission, Headley adds.
"We are always looking for gaps in care and ways that we can eliminate them," she adds.
Desert Oasis has its own staff of case managers in four local hospitals and a regional tertiary medical center who work with the hospital case managers to coordinate care.
"Hospital case managers have numerous responsibilities, and our case managers help supplement their care coordination efforts. When a consult is ordered with a specialist, they make sure the consult is done in a timely manner that day and doesn't fall through the cracks in the system because the cardiologist office wasn't notified," Headley says.
The Desert Oasis case managers make sure that when the physician orders a test or procedure it gets done in a timely manner and the information is in the chart.
"We make sure there aren't discharge delays because of lack of transportation or because the information the physician needed wasn't in the chart," she says.
The Desert Oasis case managers spend time with patients and family members and assess the patient's support system and the situation at home to determine if the patient may need additional care after discharge.
For instance, there may be an elderly patient whose wife doesn't drive after dark. The case manager makes sure the discharge happens early in the day so he will have transportation available.
Often the hospital-based care managers identify high-risk patients who could benefit from other case management programs.
When they leave the hospital, patients receive a Desert Oasis discharge card with a dedicated number to call 24 hours a day, seven days a week with questions about follow-up care.
"We want to know about it if the patient has problems understanding his medication regimen or home health doesn't come when expected. Those are things that can lead a patient back to the emergency department," Headley says.
Desert Oasis's outreach clerical staff call patients after discharge to make sure they have a follow-up appointment with their primary care physician.
A nurse case manager follows up the day after discharge to make sure the patients have gotten their prescriptions filled, are not experiencing any problems, and that their support system is in place.
"We work closely with the emergency departments at our four local hospitals. If they identify patients in the emergency department who are not necessarily being admitted but need follow up, they call our case manager," she says. Desert Oasis has case managers on call around the clock.
It has developed an intensive case management program, staffed by RNs with emergency department and intensive care unit experience to coordinate care for at-risk patients with complex needs that aren't being met.
Patients eligible for the program have multiple comorbidities, are frequently hospitalized, make frequent visits to the emergency department, or have been diagnosed with cancer.
Referrals come from primary care physicians, emergency department staff, skilled nursing facilities, home health providers, and the physician group's customer service line.
When a patient is referred to the program, the intensive case manager reviews the patient's chart and immediately calls the patient to determine what is going on.
When the situation indicates it, the intensive case manager and a physician see the patient in the home, often within an hour of getting the call.
"Whether we see the patient in person or handle it by telephone depends on the patient and the patient's needs," Headley says.
The intensive case managers assist cancer patients to get all of the tests, such as biopsies, ultrasounds, and positron emission tomography (PET) scans, completed before they see the oncologist so the patients avoid repeated trips to the physician.
"When people are being diagnosed and treated for cancer, it's a frightening time. Our case managers support them and coordinate their care to ensure it occurs in a timely manner," she says.
One patient who received intensive case management was a Medicare Advantage patient who had made several visits to the emergency department in a short period of time because he was having prostate issues and couldn't void. The emergency department staff also noticed that the patient had a benign meningioma.
The patient needed to see a urologist but because he was an alcoholic had problems making and keeping appointments.
The urologist wouldn't operate until the patient had been cleared by a neurologist.
"There was no real likelihood that this man would be able to coordinate a visit to a neurologist, then get an appointment for prostate surgery," Headley says.
Desert Oasis got the urological problem controlled and enrolled the patient in a recovery program. He finished the program during the holiday season, and since he had no support system at home, the intensive case manager arranged for him to go to an assisted living center for a couple of weeks.
The case manager then assisted him with the appointment to see the neurosurgeon to remove the meningioma, then supported him through prostate surgery.
Nearly a year later, he's still sober and his medical issues have been handled.
Desert Oasis Healthcare is part of The Heritage Companies, which include 25 medical facilities in California and New York. Richard Merkin, MD, COO, developed the model to manage medical groups and independent practice associations and integrate them with hospitals and ancillary care providers.
A comprehensive case management program at Desert Oasis Healthcare that provides care coordination for patients throughout the continuum keeps patients healthier and out of the hospital. And it's cost effective.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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