Multidisciplinary approach is key to program’s success
Case managers rely on instincts, software prompts
Physician Health Partners’ frail elderly disease management program is multidisciplinary by necessity.
"These patients’ problems are not strictly medical problems, they aren’t strictly drug interaction, and not strictly psychosocial problems. That’s why it makes it difficult for any single physician to manage one of these patients. It takes a team approach," says Jay Want, MD, medical director for the Denver management service organization (MSO).
About 500 patients are enrolled in the program. It is staffed by three RNs who manage the cases, one licensed practical nurse who does the callback program, 1.5 full-time equivalent social workers, and one pharmacist who examines the medications the patients are on and checks to make sure those medications are working.
The team works closely with the patients’ primary care physicians.
"We see ourselves as an extension of the primary care physician," adds Rosalind Bader, MSW, director of case management.
In the Physician Health Partners model, the pharmacists, socials workers, and nurses work with the same physicians on a consistent basis.
"Our philosophy is that, in order to make changes, a physician has to trust that the information is reliable, and it’s easier if they have met the person who has given it to them," Want says.
Although the community case management staff may make recommendations to the physicians, it is the physician’s option to make changes in the treatment plan or keep it the same, Want adds.
Many of the patients are referred to the program by Physician Health Partners’ case managers, who work onsite at local hospitals and skilled nursing facilities. They work together with the case managers in the community program.
The nurse case managers call patients 24 - 48 hours after discharge from acute care or the skilled nursing facility and make sure they have their prescriptions and that follow-up appointments have been made.
The nurses use a scripted questionnaire and use their judgment to call in community case management if needed. "In some cases, the nurses may call the primary care physician or direct the patient to emergency care," Bader says.
In the frail elderly program, the case managers follow the patients on an outpatient basis and contact them anywhere from weekly to monthly, depending on the patient.
Nurses do the initial assessment of patients using Pfizer Health Solutions’ Clinical Management System software. If there are no red flags, they follow up in a month. If they think the patient needs additional services, they either call them more frequently or get with the social worker and come up with a way to meet their needs.
"The software program has prompts, but many times the nurses use their judgment and skills to decide what is appropriate for the patient," Bader says. The nurses get a list of medications the patient is taking, and the pharmacist looks at the list and makes recommendations.
"The primary care physicians are the drivers of the patients’ prescriptions, but sometimes there are multispecialists, and we try to oversee the medications and make sure the primary care physician knows everything that has been prescribed," Bader says.
As they talk to the patients on the telephone, the nurse care managers often follow their instincts in deciding whether patients need a home visit or additional follow-up. If something doesn’t seem quite right, they often involve the social worker, who visits the home.
"The nurses are attuned to the medical piece, and pull in social work if other things are impeding compliance," Bader says.
For instance, patients may have cognitive defects or financial problems that can prevent them from taking proper care of themselves.
The program will provide scales for people who need to weigh themselves and can’t afford to buy their own scale.
"Home visits are part of the services. We try to keep our visits down because they are a resource-intensive component. But if we’re not sure what’s going on, we like to take a peek and see if any interventions are needed," Bader says.
The pharmacist may accompany the nurse or social worker on home visits.
"With the frail elderly, the social work component is critical to making sure they are staying safe at home and have the resources they need," Bader says. In these cases, the social workers help the patients and their families find local resources to help. The social workers work with a local Alzheimer’s project and refer patients to the program if the need it.
They work with the drug companies to get prescriptions filled for indigent people and get the patients who need it on entitlement programs such as Medicaid, Meals on Wheels, and a state energy assistance program.
"We also work with charitable organizations, like the Dominican Sisters, to provide homemaker assistance and other services not traditionally covered by insurance," Bader adds.
"We try to be really creative in hooking people up with the resources they need. The social workers are really in tune with the community agencies," she adds. n
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