Rethinking an old notion
HMO restructures case management model
Imagine a health system where payer-based case managers and clinical case managers work together in both acute and community-based programs.
It may sound futuristic, but that's what Sentara Health System in Norfolk, VA, did in October 1995 when the system's health maintenance organization (HMO) restructured its case management program. Like most HMOs, Sentara's HMO used case managers to review and approve treatments and longer stays for certain patients in its four hospitals. Now, the HMO's case managers are following patient groups in the community setting, while the hospital-based case managers have more utilization review responsibilities.
The concept Sentara is trying may be more common in the future as managed care organizations align with hospitals in fully integrated health care systems.
Sentara completed a pilot test of the new program in January for two patient groups: high-risk pregnancies and congestive heart failure (CHF), says Sharon Metz, RN, vice president of medical care management at Sentara's branch office in Virginia Beach, VA. Both pilot studies were open to any patient using Sentara's health services, regardless of insurer, she adds.
Sentara is composed of four hospitals, five health centers, 11 nursing homes, a home health agency, outpatient hospice, and a 140-member physician group practice. Sentara serves more than 175,000 enrollees in the southern region of Virginia in its health system and HMO.
Sentara's redesign is part of an effort to better manage Medicaid patients within its system. The state of Virginia divested itself of managing Medicaid patients in 1995 and mandated that those patients join HMOs. In the first year alone, Sentara's Medicaid enrollment totalled 20,000 patients.The enrollment is expected to double this year, Metz estimates.
The primary component of the restructured program is a partnering between the community-based case manager and the hospital-based case manager into a single case management program called medical management. "Before, we had our own reporting structure within the HMO and the hospitals. Both groups had a vice president of medical management. Now, it's just me," explains Metz.
For a high-risk pregnancy patient, for example, the community-based case manager conducts a preliminary screening, evaluates the patient in follow-up prenatal visits, and develops a care plan that is forwarded to the patient's primary care physician. "The community-based case manager also breaks any barriers the patient may experience in receiving care, such as arranging for transportation, or any social barriers," notes Metz.
When the patient is admitted to the hospital, the hospital-based case manager assumes supervision of the patient. Both the community-based and hospital-based case managers discuss the patient's plan of care over the telephone.
A long-term approach
If the hospital-based case manager identifies a potential problem, the community-based case manager is notified, and both discuss the patient's care before discharge planning is concluded. Long-term planning and services, such as home health visits and training for premature babies, are coordinated through the community-based case manager.
Ensuring that patients don't fall through cracks in the system was a part of the pilot programs' purpose, as well, says Metz. Developing the pilot programs required the creation of new documentation for communication between caregivers, such as authorization and outcomes reporting forms.
To help reduce the amount of paper documentation required, community-based case managers are equipped with laptop computers. And in the future, community-based case managers may be equipped with cellular telephones to enhance communication capabilities.
Outcomes goals were established for each patient group to evaluate the program's effect. For high-risk pregnancies, the goals were to increase gestational age and reduce average costs per case. For CHF, the goals were to reduce hospital admission rates and emergency department visits.
Restructuring the case management program was seen as a positive move by staff, says Metz. "This is considered a work in progress. We're evaluating the skills of each case manager to find which environment is best for them. Some employees prefer the hospital, and some prefer the community. This allowed us to match the employees' skill sets to the appropriate job."
The biggest challenge was developing a system that met the needs of both the HMO and the hospital. For some of Sentara's case managers, the restructuring meant a new mindset. "In the hospital setting, it meant transferring from a fee-for-service mentality to a managed care mentality," explains Metz.
The case management program's redesign came about from meetings attended by a managed care contracting committee and the medical management team. As a result, an ideal vision of how a patient's care is transferred from one setting to another was developed.
Based on the success of the pilot programs at meeting the desired outcomes, Sentara will incorporate the case management program into its entire delivery system, says Metz.
(Editor's note: Hospital Case Management will keep readers informed of Sentara's progress in future issues of the newsletter.) *
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