Part Two of a Two-Part Series
Chronic illness subject of successful program
Improved health, better care from partnership
Intermountain Health Care (IHC) of Salt Lake City has helped improve the health of many of its chronically ill patients through a program that places care managers in physicians’ offices.
About four years ago, when IHC began researching ways to extend its reach and improve care for the chronically ill, it assigned two home health employees to physicians’ offices and told them to help doctors manage the patients. IHC is a nonprofit charitable health care organization made up of 21 hospitals, an insurance company, clinics, and about 400 physicians’ practices. IHC serves about 500,000 clients under its insurance plan.
The pilot program was so successful that IHC added more case managers, eventually reaching a total of 12. Their mission is to educate and coach, says Jill Hoggard-Green, RN, PhD, assistant vice president of clinical support services at IHC.
What do the case managers do?
"The first year we did this, we also had a mission of improving health by focusing on health promotion," she says. "While it was beneficial from a patient’s perspective, we didn’t find a lot of outcomes of either reduction of risk factors or reduction of costs, since health behavior changes take a lot of time. But we did find if we worked with individuals with chronic diseases, we saw huge changes in health behaviors, clinical outcomes, and costs."
In a pragmatic and functional manner, the case managers assume whatever tasks are necessary to improve the health of a patient.
Each of the 12 case managers was placed in a physician’s clinic (except in one clinic where two case managers were assigned). The number of physicians at each clinic varied from between four and eight to between 12 and 48. "But we have found that once you get beyond 24, the care manager really doesn’t get to know the doctors well enough to build a relationship," she says. "The best number seems to be 12 to 15, but some people say four physicians is best."
About 70% of the patients assigned to the case managers have a chronic illness, while 32% have two or more. The top two illnesses are diabetes and asthma. But a third condition — mental health issues — often enters into the equation. "If I look at a secondary diagnosis, there were more patients with depression and anxiety as a diagnosis than there were of diabetes," Hoggard-Green says. "Almost everyone had some sort of psychosocial issue that was making it more difficult to deal with the problem."
Although they hold classes and bring groups of people together, Hoggard-Green says the most effective interventions are the ones where the case manager spends time with the patient on the telephone or in person. "It is very specific," she says. "If you are working with an individual with diabetes, it is not [about just] sitting down for an hour and going over all the foods they can and cannot eat."
Rather, she says, it involves a visit to the house or a phone call placed by the case manager who asks, "How did you do last week? What is your goal this week?" Instead of simply teaching a concept, case managers show patients how to apply a concept to their daily lives.
The care managers do facilitate complex plans of care, as most are multiple specialists who use many services and disciplines.
In following up on efficiency of the program, Hoggard-Green says some of the care managers report there are times when the needs of one patient are so complex they consume an entire day. Other times, a care manager can spend the day making follow-up telephone calls.
During a one-year period, the eight care managers assigned to physician offices handled approximately 4,000 patient visits. The average number of contacts per patient is 3.7. Hoggard-Green says the latter figure is misleading considering that in some cases the patient needs one intervention, while in others, particularly those involving patients with a chronic illness, seven to 10 visits are needed. "We let the patients tell us when they don’t need to see us anymore," she says.
Case manager empowers patient
The program’s organizers were pleased when interviews with patients and doctors netted positive results. Before they began meeting with the case manager, "Many patients said their health was going downhill, and they felt an inability to cope with an overwhelming situation," Hoggard-Green says.
Many patients described themselves as depressed, anxious, frightened, and frustrated with the lack of communication with their physician, and lacking in the knowledge and resources necessary to get their needs met.
Following intervention — and regardless of whether that intervention included one, two, three, or more meetings or communications with the case manager — patients talked about feeling "empowered" and experiencing "positive changes in their lives," Hoggard-Green says.
"We weren’t setting up dependencies," she says. "[Case managers] were coaching people into believing and understanding that they could do it and giving them the tools and the resources over time to let them do it. It was one of those fundamental values of social work and nursing, helping people help themselves.’"
When asked to describe the care manager, patients and family members used words such as caring, supportive, accessible, advocate, champion of my cause, communicates with you, coordinates with the physician, educates, and arranges for services.
"Patients felt that they had more access to their doctors than ever before," she says.
Doctors said having case managers in their office helped improve quality of care and their relationship with their patients.
"They were really worried at first about what it was going to do to their relationship with the patient," Hoggard-Green says. "There was concern that it would diminish their role. But it didn’t. Rather, the consumer attributed the intervention to the doctor, and they thought it was fabulous."
They said the case management program helped reduce the number of inappropriate trips to the emergency room, and they felt the patients’ needs were being better addressed.
Doctors also reported improved productivity, "not that they were working 10 hours a day instead of 12 hours. But they felt more productive because they could spend appropriate time with each patient."
For more information contact:
Jill Hoggard-Green, RN, PhD, assistant vice president, Clinical Support Services, Intermountain Health Care, Salt Lake City. Telephone: (801) 442-2000.
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