QI should begin with the most frail patients
Group boosts functional status up to 20%
Most candidates for disease management programs have a cluster of comorbidities. One seldom-used answer to the challenge is to proactively manage the care of those at highest risk for further deterioration. With that approach, the StatusOne health care consulting group achieves a 15% to 20% improvement in the functional status of high-risk patients. As a result, hospital utilization drops 20% to 25%. "Quality in health care has to begin with the high-risk patients," says Matt Kelliher, president of the Hopkinton, MA-based firm. "It’s the area we believe is missing in many quality programs, and we believe it’s the area where organizations can get results."
One group that incorporated the high-risk population management approach is the Lahey Clinic of Burlington, MA. Lahey’s case managers serve patients of all ages. No single diagnosis represents more than 6% of the caseload.
Using specifically designed software, case managers scan existing records from inpatient, outpatient, emergency room, and pharmacy services
to identify patients with a high risk of needing medical care on a monthly basis. Those at highest risk are placed in the "StatusOne patient registry." They are the subjects of individualized care plans and active professional support. Besides comprehensive medical care, the treatment includes health maintenance and preventive components. Goals often involve social activities to alleviate
the isolation that can accompany severe health problems.
Here are two summaries of treatment and outcomes, excerpted from Lahey’s monthly impact case reports:
1. A 43-year-old man with an 18-year history of low back pain frequently visited the emergency room. Repeated spine examinations revealed no definite physical cause. He suffered from panic attacks, depression, and social isolation.
Interventions: Mental health professionals designed a plan for more aggressive management of depression, anxiety, and self-defeating behaviors. In-home physical therapy consists of a rehabilitative exercise routine. A three-phase plan will teach him how to manage his pain, increase activity, and re-integrate into social activities.
Outcomes: No emergency room visits or inpatient admissions have occurred since the case management interventions began. The patient is highly engaged in his treatment plan and has increased his activity level.
2. A 68-year-old woman with congestive heart failure (CHF), kidney problems, morbid obesity, and a host of other problems was admitted to the hospital four times between January and April.
Interventions: The case manager, together with the primary care physician and home care agency, set criteria for weight, renal status, and diabetic control. The case manager called the patient and home health agency every other day. In-home physical and occupational therapy services helped the patient increase her strength and endurance.
Outcomes: No hospital admissions have occurred in the months immediately following establishment of the care plan. The patient achieved stability of CHF symptoms, diabetic control, and a 20-pound weight loss. She increased her physical and community activity.
Technology plays a critical role in the high-risk population management model. StatusOne provided an Internet-based software package that ties the program together. Jerry C. Maliot, MD, MS, Lahey’s medical director for utilization management, says he likes it for many reasons. "It’s a secured technology — as secure as one the Department of Defense would want. And because it’s Internet-based, we didn’t have to spend time making it compatible with our computer architecture."
Additional features of the program allow the following:
• On-line development of care plans gives case managers access to clinical guidelines, expert consultations, and medical Web sites. Eventually, they can standardize the elements that prove most successful.
• Case managers can access patient records any time and from any place.
• Primary care physicians, case managers, and home care agency staff communicate and modify treatment plans via e-mail.
• Case managers can cover for each other during vacations and holidays.
• Feedback on clinical and financial performance of the high-risk management program is accessible on demand.
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