Redesign links CMs, primary care
CMs, SWs work in the hospital, MD offices
At WellSpan Health, teams that include hospital-based case managers and social workers, and health coaches located in physician offices, work together to coordinate care.
- The case managers and social workers are assigned by physician and spend most of their time in the hospital, but are expected to spend a target of two hours a week at the WellSpan Medical Group physician practices.
- Practices that are not part of the WellSpan Medical Group are assigned a case manager and a social worker who follow their patients in the hospital but do not visit the practice.
- The initiative promotes communication and collaboration between the hospital level of care and primary care.
By changing the orientation of case managers and social workers at the hospital level to collaborate with primary care practice health coaches on care coordination for hospitalized patients, WellSpan Health is improving patient care and improving outcomes, says Ann Kunkel, RN, BSN, CPUR, corporate director of care management for the coordinated health organization, which includes four hospitals and 37 outpatient sites that provide services such as primary care, imaging, and rehabilitation in Central Pennsylvania.
The health system developed a performance scorecard that tracks patient experience, outcomes, and hospitalization and has seen improvement in all three dimensions since the initiative began, says Karen Jones, MD, director of quality and innovation for WellSpan Medical Group.
Care for hospitalized patients is coordinated by a three-person care coordination team, a health coach located at the physician practice, and a hospital-based case manager and social worker. The case managers and social workers spend the majority of their time in the hospital setting with a target of spending at least two hours a week in the office to assist the health coach in following up after discharge when needed. (For a look at how the team works together, see related article on page 172.)
The care coordination team communicates every day to ensure that the treatment team in the hospital and at the practice have the information they need to care for the patient and that all of the patient’s discharge needs are met. The team also reviews at-risk and vulnerable patients to assess their care plans and come up with ways of engaging patients to achieve healthier outcomes.
The initiative was begun as the health system reviewed its mission and strategic plan as part of its transformation to an accountable care organization.
"We thought we were patient-centered before, but this project has shown us that we were patient-focused, not patient-centered. Now the patient is the center of everything we do, and the inpatient team and physician office team are collaborating to provide continuity in care," Kunkel says.
A key component of the program is assigning case managers and social workers to primary care practices, says Marsha Braucher, RN-BC CPUR, director of acute care management.
Originally, the case management team was assigned by unit. In July 2012, the case management department began shifting to assigning case managers to primary care practices.
"We found that as patients move from unit to unit, the staff is focused on the patients’ needs on that unit, but no one had the full picture of the patients’ care across the continuum," Braucher says.
The case managers and social workers are assigned by physician practice throughout the hospital except for four areas: women and children care, maternity and the neonatal intensive care unit; the emergency department, trauma unit, and behavioral health, says Amy Shuttlesworth, BSW, manager of social services. "We have found that the practice-based care coordination staff sometimes continues to follow patients in those areas, and we plan to add these areas into the model over time," she adds.
The hospital started the initiative by assigning case managers and social workers to 14 practices but soon brought the entire department online, assigning the staff by physician. "We soon recognized that we needed to change the orientation across the department. Having unit-based and primary care-based case management staff is too difficult to manage," Braucher says.
Admitting physicians who are not part of the WellSpan Medical Group are assigned case managers and social workers, but the team doesn’t visit their offices, says Kim Romoser, CPUR, manager of appeals. "It works best to assign a team to the non-medical group the same way we assign teams to the practices in our medical group to provide continuity as patients come in and out of the hospital," she adds. For instance, if patients are admitted with pneumonia and come back later for surgery or a cardiac event, they have the same case managers and social workers they know and who are familiar with their medical history, she adds.
The program started in 2011 when, as part of its patient-centered medical home initiative, WellSpan Medical Group conducted a pilot project using case managers as health coaches within three practices. "They found there was a component missing. The case manager was spending a lot of time on social work-related issues. We brought a team together to determine how to provide this missing component to the practice setting," says Laurie Brown, RN, clinical director of quality and innovation for WellSpan Medical Group.
The team determined early on that part of the problem was that the hospital team did not have an ongoing relationship with patients as they moved through the continuum of care.
"There is such a revolving door in the hospital, and the staff’s loyalty and focus was on patients while they were on the unit. We have come to realize the value of having an ongoing relationship with the patients. We did not appreciate how changing our focus actually increased accountability for the patients, families, and the staff," Kunkel says.
The team also determined that hospital-based staff were unfamiliar with the day-to-day operations of a primary care office. "Most case managers and social workers have backgrounds only in acute care and don’t know what goes on in a physician office. We had a lot of discussions about how they can work with the team in the office," Braucher says.
Before the initiative was rolled out, the hospital placed a social worker in a physician office as a pilot to learn about how the physician office works and share the information with their peers.
As part of the redesign, the hospital system added eight FTEs in case management, and the medical group continues to evolve the health coach role, Kunkel says.
"The restructuring has been very hard for the case management team as well as for the practices, but we can see that the care coordination teams have had a meaningful impact on patient lives," she says.
