Community Case Management Thinking Beyond the Hospital Walls
By Toni Cesta, PhD, RN, FAAN
Introduction
When the Centers for Medicare & Medicaid Services (CMS) changed the way in which it would reimburse hospitals based on the number of Medicare 30-day readmissions they had, hospitals began a long journey of discovery. Initially, most of us thought that acute care hospitals would be in the control seat in terms of reducing the number of patients readmitted to the hospital with heart failure, acute myocardial infarction, or pneumonia. Certainly we could do better in many ways in terms of how we prepared patients for transition back into the community. Soon, however, we also discovered that there were wide gaps in care delivery for patients once they returned to the community, especially for those patients at highest risk for readmission, emergency department visits or other negative outcomes.
This month, we will be discussing the opportunities for better care coordination and case management of our most vulnerable patients living at home. These patients are small in numbers perhaps, but they consume large percentages of health care dollars. The greater the number of chronic conditions a patient has, the greater the number of health care resources he or she will consume. We have always assumed that this was inevitable and expected. Until CMS created reimbursement penalties, hospitals had no financial incentive to reduce the number of these patients readmitted to the hospital. In fact, hospitals were financially rewarded for patient failures in the community. Today, many states are beginning to enact similar financial penalties for higher than average readmissions within their Medicaid programs, and it is expected that many managed care plans will soon follow suit.
High-risk Patient Case Management
High-risk case management in the community provides for an opportunity to improve patient quality of care and quality of life while reducing the overall cost of care. It requires that we see the patient and family at the center of the health care system, not the hospital. It also requires that case managers develop long-term and lasting relationships with the highest risk patients. And case managers must think in terms of the continuum of care and consider the management of the patient regardless of their location along that continuum. Case management thereby moves from an episodic approach such as it is in hospitals and home care delivery models, to a continuous and strategic long-term one.
The relationship between the patient and the case manager is germane to any future care delivery models. It includes the identification of these patients, the identification of the factors placing these patients at risk, the development of plans of care that include the patient and family, and the management of precious health care resources.
Integrating Case Management Roles
When redesigning the case management department to add a community case management component, one of the first steps is to create a department that transitions across the continuum of care. The infrastructure must be designed this way, just as the case managers must approach their work this way. While the acute care case manager manages that episode of illness, there must be consideration for the fact that the goal is to return that patient to the community, preferably back to his or her home environment when appropriate. Even patients going to sub-acute for a period of time will eventually be returning to their homes. Therefore, as the patient transitions out of the acute care setting, the goal is to ensure that all possible pieces have been put into place to reduce the likelihood of a return to the ED or hospital setting.
The hospital case manager must perform an assessment that includes a comprehensive understanding of the conditions from which the patient was admitted. It must also include an understanding of what failed in the patient’s community health care management that resulted in this negative outcome. Every admission to the hospital must be seen as a failure, and a root-cause analysis should be done to determine what action steps must be taken to prevent another readmission to the hospital. Clearly not every admission will be avoidable, but many of them will be, depending on the patient’s specific high-risk criteria.
Identification of High-risk Patients
The identification of the high-risk patient can happen in one of two ways. It can happen proactively, by identifying these patients while they are still in the community, or it can happen once the patient has had multiple encounters with the health care system, particularly emergency department visits or acute hospital admissions or readmissions.
From a practical point of view, it is likely that both approaches will need to be used. Even if a patient scored low risk in the community and then was admitted to the hospital, something in his or her clinical condition or social situation may have changed or deteriorated, resulting in the visit to the hospital.
Conversely, as patients enter the community system, either the clinic or physician’s office, an assessment can be performed there that will categorize the patient as low, moderate or high risk. Risk level criteria can vary, and there is a variety of schools of thought as to what places some patients at higher risk than others. One starting point can be to select the diagnoses that are resulting in the most readmissions to your hospital. You may also want to focus on the diagnoses that CMS is focusing on for readmission penalties. Right now, these include heart failure, acute myocardial infarction, and pneumonia, but CMS will be adding more each year.
Using this approach, you can track patients with these diagnoses and then add additional risk factors to the equation. Additional risk factors might include the following:
• number of hospital admissions in the prior six months;
• number of hospital readmissions in the prior six months;
• number of co-morbidities;
• age;
• socioeconomic status;
• health literacy;
• ability/willingness to be compliant.
A combination of risk factors and chronic diagnoses will ensure that you have selected the highest-risk patients. No single element listed here alone can place a patient at high risk, but rather some combination of elements. If a patient has heart failure but is adherent to her diet and medication regimen, she will not need to be classified as high risk. If another patient has heart failure, but routinely winds up in the hospital because he does not take his medications or goes off his diet restrictions, then this patient may need to be classified as high risk. Both patients have heart failure, but one needs much closer case management than the other.
If approximately 5-10% of your patients fall into the moderate-risk category, you are likely on the right track in terms of your indicators. If the percentage turns out to be higher than that, then you may want to tighten up the criteria unless you have the resources to manage larger numbers of patients.
Moderate Risk
Another 20% of your patients should fall into the moderate-risk category. This is sometimes also referred to as the "rising risk" category as it represents patients who may be on the cusp of becoming high risk if an intervention does not take place. These patients typically do not need professional case management in the form of a registered nurse or social work case manager. They can be managed via telephonic reminders, electronic monitoring of their blood work and appointments and occasional check-ins if appointments are missed.
These patients should be reassessed for risk level if they have a hospitalization, a visit to the emergency department, miss multiple appointments or have worsening of their medical condition. Additional factors may include new comorbidities, a change in socioeconomic status, or an acute illness.
Case management staff in the emergency department or hospital can play an important role in helping to identify patients whose risk level has changed. This identification can take place when the patient is initially assessed. At that point, a contact should be made with the community case management department to determine what additional case management services the patient might require.
Risk levels are fluid. Patients may increase or decrease in risk level at any point. For example, if a high-risk patient has not been hospitalized or been in the emergency department for a six-month period and his or her clinical status is improving, this patient may be appropriate for a down-grade to moderate risk. Conversely, the patient who is moderate risk and has any of the changes listed above may need to be upgraded to high risk. According to The Advisory Board Company, approximately 18% of the rising-risk or moderate-risk patient population will become high-risk in any given year. (Playbook for Population Health, www.advisory.com/pophealthplaybook.)
Low Risk
The remaining 70% of patients fall into the low-risk category. These are patients who have none of the risk factors as described above and who are generally stable and self-managing. They may be completely healthy individuals. They may have chronic conditions that are well-maintained.
These patients are as important as the moderate- to high-risk patients in terms of keeping them healthy and stable. They need to be connected to the health care system, as should all patients. As providers, our goals for these patients would include providing a level of care and involvement with these patients that keeps them loyal to our health system or medical home. We want to keep them as healthy as possible by ensuring that annual routine check-ups take place and that these patients don’t fall through the cracks. By maintaining a database on the low-risk patient population, your system or medical home is in a better position to treat them should care be needed at any point.
The best way for these patients to interact with the health system is through a patient portal where they can participate in the management of their care and interface with the health care system or medical home.
Patient Registries
Patient registries are another important tool for managing high- and moderate-risk patients. These are clinical information systems that provide a foundation for actively following large numbers of patients. Registries provide a technology solution to managing large populations of patients. For low-risk patient groups, they can be used to trigger patient appointment scheduling, routine blood work or annual tests such as mammograms or colonoscopies.
For moderate-risk patients, the registry can be used to trigger the above, plus additional clinical management issues that may be specific to the moderate-risk patients. These may include more frequent appointments with the primary care provider. Beyond these issues, the moderate-risk patient may need monthly telephonic or face-to-face meetings with the social worker and/or case manager, depending on their issues.
For the high-risk patient, they will need to have their blood work monitored closely as well as any other frequent tests or procedures that need to be performed. The software can alert the case manager when blood work results are abnormal or when a patient does not keep a scheduled appointment. Expected outcomes can be entered into the patient’s database so that all care providers know the patient status and can review, with all of them looking at the same information in the system. In addition, the social worker and case manager will need to keep a close and diligent eye on their status and progress.
Finally, registries can be used to assess populations of patients to determine how your organization is doing in terms of any and all of the issues listed above. These data can be used to identify areas for improvement, gaps in care, or other issues requiring intervention or improvement.
The Role of the Acute Care Case Manager in Community Case Management Systems
Acute care case managers can no longer work in siloes, isolated and apart from the rest of the health care continuum. Solutions to many of today’s care delivery issues, such as transitions in care, readmissions, and recidivism, require that case managers based in hospitals keep an eye on the patient’s pre-admission issues and post-discharge needs. This begins with an assessment of the patient’s risk level as discussed above.
When your patient is admitted to the hospital, your initial admission assessment should include an analysis of the patient’s prior living situation, including family and other support systems. If the patient is a readmission within 30 days, then it is imperative that you assess what the root cause(s) of this readmission were. This is an important part of your admission assessment because it will determine the following:
• If the patient’s clinical condition is worsening.
• If you need to make a referral to the social worker.
• If the patient can return to their prior living situation. (Is it safe?)
• If the family caregiver is adequate.
• If the patient is unable to manage his or her medications at home.
• If the patient is unable to manage his or her diet at home.
In addition to gathering this information, you should check your electronic medical record (EMR) to determine who the patient’s primary care provider is in the community and what the risk level of the patient is. Your system should be set up so that the patient’s prior risk stratification level is available to you as well as the assigned community provider, case manager, and social worker, if appropriate. Once you have gathered this information, then you can notify these providers regarding the patient’s admission, and issues that preceded the return or admission to the hospital. It is also recommended that the community case manager and/or social worker visit the patient in the hospital. This approach to coordination of care, as well as continuity of care, can result in fewer gaps or redundancies in care. Ultimately, these interventions can provide the care team with the information they need to improve the patient’s clinical situation and/or quality of life.
Summary
Case managers must approach the case management process as one that focuses across on the continuum of care and addresses inpatient as well as community needs. Case management assessments must go well beyond just the issues of discharge destination, but rather connect the care providers across the continuum in new ways that will improve outcomes for patients and reduce cost for the healthcare industry.
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