Members set personal goals rather than clinical milestones
When the case managers at HealthPartners work with patients who are at risk for clinical complications, they focus on helping their clients meet personal goals, not those of the health care organization.
"It's important to be patient centered and know what the patient's goal is. Then everything else lines up with that," says Karen Kraemer, RN, CMC, senior director of HealthPartners case management program. If the case managers know a patient's personal goals, they can help them set clinical goals and understand what they need to do to attain the goal."
HealthPartners is an integrated nonprofit health care organization based in Bloomington, MN, that provides health services, insurance, and HMO coverage to more than 670,000 members.
Members are treated by the HealthPartners medical group and clinic or by contracted medical groups or health care systems.
When asked about their health care goals, patients don't want to say they want to get their hemoglobin A1C to a certain level, Kraemer reports.
Instead, they tell their case manager that they want to be able to walk their daughter down the aisle in a few months or travel to see the birth of their grandchild, Kraemer says.
One young girl with a debilitating disease wanted to be able to attend her senior prom and walk down the aisle with her class at her high school graduation.
Finding the patient's main goal is a major motivating factor, says Diane Reuss, RN, CMC, outpatient case manager.
"The goal may not be health-oriented, but we help connect it so that they see that if they make a lifestyle change, they may be able to meet that goal," she adds.
For example, an older woman told Reuss that she wanted to be able to clean her house, go grocery shopping, and take care of other activities of daily living independently. She needed knee replacement surgery to be able to do so, but her weight, diabetes, and hypertension made the surgery risky.
Reuss referred the client to HealthPartners' Center for Health Promotion's diabetic education program and called her frequently to reinforce the dietary and lifestyle changes.
With Reuss' encouragement, the woman started exercising, improved her diet, and got her blood sugar, blood pressure, and weight down so she could have the surgery.
Since HealthPartners began its outpatient case management program, the per-member per-month cost has dropped 24.7% and the hospitalization rate for those patients has dropped 48%.
The proportion of members on the registry who have active care plans is at 96%, compared with around 85% in 2002. An active care plan means the member has agreed to take at least one meaningful action to improve his or her health.
Studies by Status One, a medical management company with which HealthPartners contracts to identify patients for its case management programs, show that health plans begin to see a financial return when 70% of their members have active care plans, Kraemer says.
The patients' acuity level has improved by 7% since the program started.
The members' self-reported functional status has increased 13%, and the number of people who report that their functioning is "poor" is steadily decreasing.
"All of the indicators tell us we are having an impact, not only financially but from a patient assessment of functional status and their risk for acute care services," Kraemer says.
HealthPartners' outpatient case management program is very different from traditional case management and disease management.
"These people aren't getting triggered because of a financial threshold or a particular diagnosis. They are picked for the program because of the potential that they will need acute care," Kraemer adds.
Through a partnership with StatusOne, HealthPartners identifies people who may be at risk for health care problems through a predictive modeling system.
The software takes claims, pharmacy, and membership data and uses a proprietary algorithm to develop a clinical profile on highest-risk patients. The patients who are most likely to develop clinical complications with high costs within a year are assigned to nurse case managers.
"The algorithm is not based on disease or financial costs. These are people who are at risk for major health problems, not just those who cost a lot of money," Kraemer says.
Referrals also come from physicians, from inpatient case managers, from HealthPartners' Center for Health Promotions health assessment and education program, and from community organizations whose staff are familiar with the services that HealthPartners provides for members.
Case managers call each member in the program, conduct an assessment, find out what their concerns are, and work with them on lifestyle changes, goals, and priorities, Reuss says.
"We look at the whole person, not just the diagnosis and one specific disease. We look at what could be the causative factor for their problems. It could be diet, smoking, lack of exercise, or emotional factors such as stress or depression," she says.
The patients in HealthPartners' case management program often have five or six comorbid issues along with significant psychosocial issues. Almost all of them are depressed. Either they haven't been diagnosed or they aren't following through and getting help. The case managers are trained by HealthPartners' behavioral health team to screen for depression.
"We work with their physicians to make sure that the medical and emotional goals mesh and collaborate with their physicians to make sure we're both coming from the same direction," Reuss adds.
Based on the case manager's assessment and clinical judgment, patients are assigned an acuity level. An acuity level of 1 means the patient is likely to be hospitalized within one to three months. Members who achieve acuity level 5 are ready to be discharged from the program. The acuity level determines the minimum contacts the case managers will make with the patients.
The case managers help the members overcome any obstacles to getting care and reaching their goals.
They may not be able to get to their physician's appointment because they have transportation problems, or they may not be able to cook healthy meals for themselves.
"Any of these problems could result in the patient landing in the hospital," Kraemer adds.
Once these barriers are removed and the patients start to feel better, they are ready to tackle something else, Kraemer adds.
For instance one girl who was legally blind lost her ride to the clinic. The case managers gave her information on transportation options that got her back on track with her physician visits.
The case managers focus on helping the patients become self-reliant. For instance, the case managers don't make the transportation arrangements. Instead, they give the members the information they need to arrange their own transportation.
"We don't want them to become dependent on the health care system. We want to promote independence and self-reliance. It not only helps the system but it helps them feel good about themselves," she adds.
The case managers help patients connect with community agencies and other services they may need.
For instance, one of Reuss' clients was very sick but wanted to travel by car to Wisconsin to see his brother, who was dying. Reuss helped him find places along the way where he could replenish his oxygen supply. She found places along the route where he could get his blood drawn and made sure he had enough medication for the trip.
"In this case, we had to work with long-distance carriers to make sure the patient would be safe during his journey," she says.
HealthPartners has about 3,000 patients on the case management registry and 30 case managers who manage an average of 80-100 patients each.
The case managers are assigned according to the care systems, which include the HealthPartners medical group and clinic as well as a number of other medical groups and independent physicians that have contracts with Health Partners.
"Nurses are assigned according to care system so they can build relationships with those physicians and understand how that particular care system works," Kraemer explains.
Depending on the patient load, case managers may cover several medical groups, or several may be assigned to one large medical group. The patient identifier algorithm is based on the pattern of care, treatment, and place of service.
"We look at case loads and acuity levels; and if we need to juggle the patient load, we do so, but for the most part, we are able to divvy up patient care based on which clinic or medical group cares for the patient," Kraemer says.
When the case managers at HealthPartners work with patients who are at risk for clinical complications, they focus on helping their clients meet personal goals, not those of the health care organization.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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