Community CMs bridge gaps in the continuum
May 1, 2009
Community CMs bridge gaps in the continuum
Clients get help navigating system
When an elderly woman continued to have elevated blood pressure after her physician prescribed a medication regimen, the doctor assumed the patient was confused and not taking her medication properly.
That's where Cyndy Luzinski, MS, RN, came in.
Luzinski, a community case manager for Poudre Valley Health System in Fort Collins, CO, had helped the client manage the ordering and administration of her medication and had her use a pillbox to facilitate compliance. She knew the woman was taking her medication correctly.
"I talked to the physician and convinced him that despite previous confusion with taking the medication correctly, the client now was taking the medicine as prescribed. The doctor added another medication, which solved the problem. If I hadn't been there to advocate for the patient, the physician might have continued to assume that the blood pressure elevation was because the client was confused and noncompliant with her medication," she recalls.
Without a case manager to monitor the client, her medication compliance and blood problems likely would have continued, causing her to be hospitalized, Luzinski says.
Meeting a need
Luzinski is one of six community case managers who help patients from Poudre Valley Health System learn how to navigate the health care system, make lifestyle changes that will keep them healthy, follow their treatment plan, and avoid unnecessary hospitalization and emergency department visits.
"Our clients are those who might otherwise fall through the cracks in the health care system. We meet a need in the community and bridge the gaps in the continuum of care to help people stay independent in their own homes," Luzinski says.
When they get new clients, the case managers make an appointment to see them in their homes to assess the situation.
On the first visit, the case managers complete a complex assessment that includes information on the client's physical issues, psychological health, the client's family and community support, and whether he or she has advance directives.
They perform a noninvasive physical assessment, checking the client's heart, lungs, blood pressure, and signs of edema.
They develop individualized care plans that may include talking to the client's physician, accompanying the client to office visits, assistance with medication management, and coordinating transportation.
"The relationship they build up with the clients is immense. They develop rapport and trust and can be the eyes and ears of the primary care provider. Because they are in the home and work closely with the clients, they can identify and solve problems that the physician might not know about until the client is admitted to the hospital or visits the emergency room," says Donna Poduska, MS, RN, NE-BC, NEA-BC, director of resource services for the 225-bed hospital.
Link to system, community
The case managers help the clients negotiate the health care system and learn about and sign up for community resources for which they qualify.
For instance, the case managers help the clients sign up for Meals on Wheels or transportation assistance. If a client wants to stop smoking, the case managers help him or her access a smoking cessation program and put him or her in touch with community agencies that will pay for a patch if the client will go for counseling.
The case managers have helped some clients who qualify for Medicaid enroll in the program. When Medicare rolled out its prescription benefit, the case managers spent a lot of time helping their clients determine which program was best for them and helping them sign up for the benefit, Poduska says.
Many of the elderly clients are taking multiple medications and need help with medication management.
"Some of them have so many prescriptions that it's overwhelming. They won't say so at the doctor's office, but some of them get home and decide that their medication regimen is so confusing that they won't even deal with it," Poduska says.
The case managers follow up with the physicians to ensure that the medication the client is taking is the medication prescribed. The case managers help the clients learn how to use a pillbox or develop another system for taking medication.
"We do whatever we can to help them comply with the treatment plan. Many times, the patient can't remember what the doctor said or is confused about following a complicated plan," Luzinski says.
Nutrition support
For many patients, nutrition is a problem because they have difficulty cooking their meals.
"They don't know about community resources. We can help them find someone they can hire to come in and fix their meals or refer them to home- and community-based services through Medicaid that provide meals and assistance with household chores," Luzinski says.
Sometimes the case managers can mobilize neighbors or people from the client's church who can provide meals or household help.
The frequency with which the community case managers visit their clients ranges from once a week to once a month, depending on the clients' needs.
Typically, the case managers visit once a week in the beginning, then taper off as they connect the clients with resources in the community.
"We follow them as long as it takes to get them back on track. If they just need to identify and connect with resources, we will work with them for a short time but let them know that they can always call us back. We see some of them for a long time if they are really having problems managing on their own," Luzinski says.
When an elderly woman continued to have elevated blood pressure after her physician prescribed a medication regimen, the doctor assumed the patient was confused and not taking her medication properly.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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