Avoiding admissions drives ambulatory savings
What happens between visits critical
While traditional case management tends to focus on the episode of care, the Lahey Clinic’s High Risk Patient Management Program begins when the patient is identified and continues until the patient dies, disenrolls, or gets better.
"Traditional case management focuses on managing the length of stay in the hospital. Our program focuses on managing the admission rate," says Jerry Maliot, MD, MS, medical director of the Lahey Clinic Community Practice Network with headquarters in Danvers, MA.
Each case manager carries a caseload of 75 patients, and each manager is assigned to a group of doctors.
The purpose of the project is to take a pro-active stance to help patients avoid hospitalization and emergency room visits and to look for alternatives to hospitalization, such as skilled nursing facilities.
After patients are identified and put on the program’s high-risk registry, they receive a letter from their primary care physician, introducing the case manager and saying that the physician and case manager want to work with the patient to improve his or her health.
"It’s important to link the case manager to the doctor. Often patients see case managers from health plans as people who want to take services away from them," Maliot says.
The process includes a 38-question health assessment survey patients complete. The response rate to the questionnaire has been 85%. The case manager then meets with the patient in person and takes the information from that visit along with information from the medical records, the patient’s appointment and admissions history, and anecdotal information from the primary care physician. All the materials are used to complete a patient assessment form.
Computer software that contains a template with drop-down menus make it easier to input the data. Once the case manager develops a care plan, it must be approved by the primary care physician
The care plans are patient-specific and are generated individually. The system software is set up so the case manger can fill in a template with the patient information and care plan and can dial up every day to find out what each of her patients is supposed to do that day.
"The plan is generated by case management and the software is only a documentation system," Maliot says. He adds that the data must be written down and accessible so that when the case manager is sick or on vacation, someone else can dial in and manager her patients.
Doctor is the bus, case manager the engine
The case managers have far more time than the physicians to deal with patient questions and to educate them on their conditions and how to improve their quality of life. They also deal with psychosocial issues, such as problems with family members and lack of transportation, that can affect outcomes.
"It’s not as if the primary care physician doesn’t try to handle it but we are bringing in other resources to bring all the pieces together. The primary care physician is driving the bus but the case manager is the engine," Maliot says.
For instance, a typical office visit lasts 15 minutes. A high-risk patient may come in with a lot of issues. The case manger follows up and may find that the patient didn’t understand what the physician advised.
"What drives good outcomes is not what occurs at the physician visit but what happens between visits," Maliot says.
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