Lacking community-based case management?
If so, look at this pilot program for Medicare
If you’re looking to expand your case management program from the inpatient arena to the community, consider doing what a Connecticut hospital is trying: a pilot project with a group of community-based physicians to reduce hospitalizations and improve services to Medicare patients.
Pat Cannon, MSW, MS, manager of case management and social work at Bridgeport (CT) Hospital, says an inpatient case management program begun in 1994 has been highly effective. It’s also physician-based and includes case managers who are assigned to specific panels of physicians.
"It’s been successful in many ways," Cannon notes. "It’s reduced length of stay, patient satisfaction has improved, and we feel the quality of care is better. Patients are getting tests in a more timely fashion and the pathways are being utilized and adhered to."
She says she and her colleagues decided to expand to community-based case management in hopes of reaching even more patients as managed care becomes an increasing part of the hospital’s business. In particular, they chose Medicare patients because they are elderly and often underserved. The year-long pilot program began in September of this year, and the physician group involved in the project includes a variety of specialists.
"The doctors see these patients with chronic illnesses diabetes or CHF who are in and out of the doctor’s office and aren’t managing particularly well on their own," Cannon explains. "So they come into the hospital and [emergency department] more. Our goal with community case management is to reduce some of that and provide additional educational programs."
Program is partnership with physicians
The pilot program is a partnership with a six-physician practice in the area with a large Medicare population. Cannon has sent out a questionnaire to the Medicare patients in the practice asking them about these kinds of issues:
• the patient’s living arrangements;
• the patient’s health conditions, such as arthritis or hypertension;
• how often patients visit with or talk to other people;
• how many times patients have been to the emergency department in the last six months;
• how many doctor visits they’ve had in the last six months.
The questionnaire also includes questions on any difficulties patients have with activities of daily living, such as meal preparation and using the toilet.
A nurse and social work case manager have been hired to screen for risk factors with the questionnaire and follow up with patients as needed, says Cannon.
"We also will be meeting with the physicians as we get their input on our findings from the questionnaire," she notes. "They may know some of their patients may not have answered [the questionnaire] too honestly and may need another follow-up visit."
Patients will then be classified as low risk, intermediate risk, or high risk. Low-risk patients are self-reliant and have conditions such as hypertension that are well-managed with medication; an intermediate-risk patient may have a chronic illness such as diabetes with symptoms that are managed, but the patient needs education. There are two categories of high-risk patients: high-risk moderate and high-risk intensive, says Cannon.
High-risk moderate patients are those with a chronic disease or debilitating illness who need more than one contact per week on an ongoing basis. They have an impaired ability to manage their disease and require multiple hospital/ ED/physician visits, she explains. Interventions they require include blood pressure monitoring, weight monitoring, and medication review.
"They’re just able to get around, and they fluctuate in and out of the high-risk intensive and high-risk moderate intensive [category]," Cannon notes. "They really need follow-up. We’re going to see those people every week."
High-risk intensive patients have an acute illness or acute exacerbation of a chronic diseases. They require intermittent or frequent visits of more than once a week, and they are homebound except for physician office visits. They require technical skilled interventions such as IV therapy, and they require rehabilitation interventions, says Cannon.
"The high-risk intensive patients are those who right now are [receiving] home care," Cannon says.
Patients followed weekly by case managers
If a patient has been on home health care and no longer requires it, the case managers will start following him or her weekly. About 50 to 75 patients will require those services, she estimates.
"We’ll provide transportation to the hospital so the two case managers can see them here," Cannon explains. "If we need to go to the home, we’ll go to the home."
Case managers will screen patients for both medical and social problems, because she says, "many of these patients are also depressed and isolated and have social issues that are prohibitive to them getting better."
For example, many of the frail elderly are at risk of falling in their homes, says Cannon. Case managers can obtain necessary equipment for patients such as walkers or home care for patients who have particular difficulty with mobility.
"Or, we may have to get the patient to the doctor to see if it may be the medication that places the patient at risk of falls," Cannon explains. "Maybe the patient is on [combinations of drugs] that aren’t sitting well with them and causing dizziness.
"We’re hoping the case managers will really form a bond with these people so [patients] become interested in their own health as well," she adds. "We hope to have patients stay out of the emergency [department]. But if they do come into the hospital, they won’t be as sick, and they won’t need to stay as long."
Seven-day-a-week coverage will be available; case managers will carry beepers and respond to problems as they arise, Cannon adds.
Although it is too soon to tell how well the program is working, she says expectations are high. Physicians in other groups have expressed an interest in becoming part of the program if it’s implemented on a broader scale. But Cannon says she anticipates community-based care will become standard as more managed care contracts come to the hospital.
"Managed care is coming to us, and if we can help that population reduce some of their high-cost needs for care and provide better education and quality of life, we’ll be ahead of the game," Cannon explains. "We want to be able to demonstrate to managed care that we can manage their Medicare patients for them."
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