Risk identification doesn't have to be problematic
Case managers can use assessment steps
One of the biggest challenges for community-based case managers is identifying patients at risk for hospitalization and other medical interventions before they need those services. In fact, risk assessment can make or break a community-based case management program, says Cathy Michaels, RN, PhD, associate director of community health services for Carondelet Health Care in Tucson, AZ.
"Risk identification is the glue that holds your case management program together. [Risk identification] is the right service at the right place, in the right time, for the right cost," Michaels explains. Carondelet is managing frail elderly patients throughout the continuum of care in a nurse-managed community care model.
Carondelet has three types of case managers within its system. Nurse case managers follow high-risk patients over time. Clinical case managers are clinical nurse specialists based in the acute care setting to handle high-risk patients. Specialized case managers coordinate care in rehabilitation and behavioral health settings.
Carondelet helped pioneer the field of community-based case management, and the health system created a new health network last November. The new organization incorporates a physician-hospital organization and allows the nurse case manager to coordinate care in the following health care sites:
* primary;
* outpatient;
* hospital;
* transitional;
* skilled nursing facility;
* home health;
* hospice.
Carondelet's risk identification system was developed for frail elderly patients with one or more chronic conditions in the Healthy Seniors Program. Both Medicare and Medicaid patients are eligible for nurse-managed care in Carondelet's community health centers. Conducting risk identification should be an ongoing component in a community-based program, says Michaels. "Risk identification is a process, not an instrument. Some patients have several coexisting conditions and can't be categorized," she explains.
Risk identification also can be costly. Carondelet's efforts took nine months to complete and included follow-up surveys and a 15-minute average telephone call by an RN. Staff and administrative costs associated with reaching each member totaled an estimated $600, Michaels notes.
Carondelet identified at-risk elderly members with four steps:
1. Classify members by risk.
Members of Carondelet's Healthy Seniors program were assessed on the potential for needing future medical care. Members admitted for nursing home or hospital stays during a six-month period were screened for several factors to determine their level of risk as high, moderate, or low.
High-risk patients are those who need institutional care and are experiencing functional decline. Moderate-risk patients experience complications and progression of chronic disease, but require no institutional care. Patients with a chronic illness who don't experience complications, but do not adopt suggested changes in lifestyle for a chronic condition are considered low risk.
Factors included in determining a risk level are:
* hospital admission;
* nursing home admission;
* age;
* living alone;
* diagnoses of congestive heart failure, diabetes, and/or cerebrovascular disease;
* health status self-rated as poor.
Identifying at-risk patients turned out to be a bigger challenge than originally anticipated. "We asked the primary care physicians to identify their patients who were high-risk or had experienced functional decline, but they weren't able to do that," explains Michaels.
Another problem for staff was pulling patient information from the health system's four hospital information systems. "Each hospital uses a different system, and all the information had to be input into Excel to identify the at-risk patients," says Michaels. Excel software is manufactured by Redmond, WA-based Microsoft.
After Carondelet's original pool of 1,741 members were screened, a total of 94 were identified as at-risk patients.
2. Evaluate the level of risk for patients.
Michaels and her staff took the list of nursing home and hospital admissions, and further evaluated the members with an additional set of criteria.
Members with recent nursing home admissions, for example, were assessed for the following:
* functional disability;
* dementia;
* impairments in activities of daily living;
* enrollment in state or federal medical assistance;
* health status self-rated as poor.
3. Target interventions to patient groups.
Carondelet's case managers focus on interventions most likely to change a member's lifestyle habits. Other interventions include educational programs on caring for the elderly and classes on advance directives.
"Always leave yourself a safety net when targeting your interventions. Don't include choice outliers with the other members when collecting outcomes data. There will always be one or two who simply do not want to abide by your instructions," Michaels says.
4. Evaluate risk identification efforts.
The last step in conducting a risk assessment is determining if the targeted interventions worked, says Michaels. Carondelet surveyed both physicians and members. Staff nurses called members to see if their self-reported health status remained the same or improved. Staff also asked patients if they received care in a nursing home or hospital after seeing or hearing from the nurse case manager.
Although the Healthy Seniors project is scheduled to end this December, Carondelet may continue the program in the future with specific patient groups, says Michaels. "Our costs for each member are almost $22 per month, but if our capitated rate is $80 per month, this program would not be cost-effective, so future programs may have to be modified to cut costs or target the program to patients with certain conditions, such as high-risk pregnancies or asthma."
For case managers considering implementing a risk identification process, Michaels recommends including a short-term and long-term strategy. Short-term strategies should focus on decreasing high-risk factors within the targeted patient group. Long-term strategies should attempt to decrease moderate- and low-risk levels, she says. *
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