Breaking through hospital walls: Case managers build bridge to primary care
Capitation motivates doctors to support CMs in their offices
The patient, an elderly Hispanic woman who lived with her son and his family, suffered from a host of chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, and diabetes. Now, she was calling her physician’s office, a large family practice group in Tucson, AZ, with the news that she was developing a major urinary tract infection.
Because the woman was bedridden and had no means of transportation, many physicians’ offices would simply have summoned an ambulance to deliver the woman directly to the hospital. But Nancy Swank, RN, BSN, a case manager based in the family practice group, intervened instead by going to the home, getting the woman on antibiotics, and heading off the need for an emergency room visit.
Such interventions aren’t unusual for Swank, a system case manager for HealthPartners of Southern Arizona, the Tucson-based integrated delivery system that includes the physician’s office where she works. Having spent 18 years as an acute care nurse six of them as a cardiothoracic case manager she’s worked both sides of the case management fence and has found satisfaction working outside hospital walls.
"I used to follow a patient throughout the hospital stay, maybe five or six days. And I always thought, wouldn’t it be nice to be able to actually go into their home and assess their wounds and their status and have that continuity?" Swank says. "Wouldn’t it be nice to break down those barriers so that the hospital case manager could cross from inpatient to outpatient?"
She adds that while home care can help, coordination among different stages of care is still very fragmented. (See related story about home care agencies, p. 116.) "There’s something to be said for the same eyes seeing the wounds, the same ears listening to the patient," says Swank.
The problem with home care is that it provides a safety net only for specific conditions, adds Virginia Del Togna-Armanasco, RN, medical/ surgical unit nurse manager at Lake Mead Hospital Medical Center in Las Vegas. Del Togna-Armanasco also was responsible for setting up the case management department at Tucson Medical Center.
Take a peek inside medicine cabinets
A case manager working out of a physician office can manage complex patients on a longer-term basis, says Del Togna-Armanasco. She cites the example of a woman with chronic obstructive pulmonary disease who lives alone, having lost her husband during the past year. "She gets short of breath at night. She gets anxious. When she gets more anxious, she gets shorter of breath, and ends up in urgent care because there’s nobody there who’s looking at this lady and the scenario that’s going on with her," says Del Togna-Armanasco.
Swank specializes in what Del Togna-Armanasco calls the "holistic approach" to community case management. During home visits, she asks permission to check the patient’s refrigerator for clues about eating and drinking habits. She also checks medicine cabinets. "You’d be amazed what you can find in there," says Del Togna-Armanasco. "Some have drugs that are years old." Del Togna-Armanasco adds that by visiting a patient’s home, a case manager can often get much more accurate information than by questioning the patient in the health care setting.
Having case managers coordinate care with physicians can be especially beneficial because physicians haven’t always placed a premium on prevention and wellness, says John Borg, RN, MS, vice president of clinical services at Winchester (VA) Medi cal Center. "I’m not saying we don’t need phy si cians," says Borg. "But frequently, they manage [diseases] as unconnected episodic events, not integrating all the elements of care. They only know the patients when they contact him or come into his office or go to the emergency room."
The trick, of course, is to incentivize physicians to accept case managers as a valuable and even necessary addition to their offices. And nothing bolsters physician acceptance like the specter of capitation, the managed care payment system in which physicians receive their reimbursement up front on a per-member-per-month basis. With a set budget every month, and a pool of patients for whom the physician has accepted risk, physicians’ priorities shift drastically, explains Daniel Temianka, MD, medical director for quality management at Los Angeles-based HealthCare Partners, a capitated integrated delivery system with more than 300,000 enrollees.
To succeed under capitation, physicians must focus on lowering their cost of doing business. That means accepting the need for outcomes measurement and promoting preventive health initiatives to lower the number of unnecessary office visits. It also means embracing case management, says Del Togna-Armanasco. "Capitation incentivizes physicians to be as efficient as they can and also to promote wellness," she says. "That’s why we’re seeing more immunization for the elderly for pneumonia and the flu: to keep them from getting those things, so we can keep them out of hospitals and doctor’s offices."
Swank, who works for a capitated integrated delivery system, says practices in the system are clamoring for case managers to join them. "Those that already have case managers say they’re fortunate to have them," says Swank. "With me in place here, they’ve been able to tap into some things in the system that put them on the cutting edge of health care. Because I’m here, I can introduce them to those things. They don’t want me to go."
Performance review ensures quality
At HealthCare Partners in Los Angeles, the delivery system is capitated, but individual physicians are not, says Temianka. This allows the system to sidestep possible criticism about capitation’s supposed negative influence on physicians to undertreat patients. Instead, the system has established a Provider Performance Review Committee, which grades physicians annually on quality of care, chart reviews, staff input, and patient satisfaction. Results of the review are tied to bonuses and advancement within the organization. "So there’s a very tangible and very explicit structure by which our physicians’ performance is assessed," says Temianka. "That’s critical to ensuring positive outcomes."
Incentivizing physicians to accept case management has been a trickier proposition at Winchester Medical Center, given that the community there has experienced less than 5% penetration by managed care. Even so, Borg reports remarkable success in getting physicians there to buy into the case management concept, with its emphasis on reducing costs through wellness and decreased office visits and hospitalizations.
In fact, Winchester recently conducted a pilot project in which its case managers went into four local physicians’ offices to assess the charts and records of 200 patients with diabetes. During the course of their review, the case managers found a wide variance in how each of the offices managed their patients, and how well they were able to achieve patient compliance with the treatment regime. That’s helped open some physician’s eyes to the need for case management regardless of reimbursement structure.
An early adapter, Winchester established its case management department in 1989, says Borg. "And the physicians’ offices that invited us in [for the diabetes project] had previously sent us patients that either had COPD or CHF, and we had managed those patients and decreased significantly the number of unexpected office visits, ER visits, and overall hospitalization, basically by putting them on patient management programs."
Borg says one way to improve physician acceptance of case management in the absence of capitation is to look at which patients are most frustrating for physician practices to treat. "Physicians are not particularly interested in chronic patients," says Del Togna-Armanasco. "They like a problem they can solve, and chronic illness is chronic." By easing physicians’ frustration over noncompliant and chronically ill patients, you can dramatically improve relations between physicians and case management, Borg says. "Once you make those inroads, you begin to develop a relationship," he says.
Even so, forming such relationships in a fee-for-service environment requires a mutual recognition that cost containment will be the key to future success, says Borg. "The tricky part about this is that when you’re talking about cost avoidance, you’re taking money away from the hospital and away from the physicians," he adds. For example, in 1993, Winchester received about $1.3 million in charges for its case-managed/doctor-referred COPD and CHF patients. In 1995, that figure dropped to less than $300,000. "Now, if you ask our finance office, we lost a million dollars in revenue. But it’s vital to effectively manage the transition from fee-for-service to managed care. If you don’t get it done, managed care will come in and you’ll be scrambling and might not have the money to do it then. Right now, we have the revenue, so we’re doing it."
For more information about case management in the physicians’ office, contact:
John Borg, RN, MS, vice president of clinical services, Winchester Medical Center, 1840 Amherst, Winchester, VA 22601. Telephone: (540) 722-8030.
Virginia Del Togna-Armanasco, RN, nurse manager, medical/surgical unit, Lake Mead Hospital Medical Center, 1409 East Lake Mead Blvd., Las Vegas, NV 89030. Telephone: (702) 649-7711, ext. 5362.
Nancy Swank, RN, BSN, system case manager for HealthPartners of Southern Arizona, based in Tucson. Telephone: (520) 742-4159.
Daniel Temianka, MD, medical director for quality management at HealthCare Partners, 1025 N. Olympic, Los Angeles, CA 90015. Telephone: (213) 861-5906.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content