CMs assist with transitions for at-risk members

CMs assist with transitions for at-risk members

Comorbidities, gaps in care are also targeted

When Cigna members at risk for readmission are discharged from the hospital, the health plan’s RN case managers follow them for an average of 30 days to assist with transitions and help the patients understand their treatment plan and follow it.

Cigna targets diagnoses that have a high readmission rate and uses predictive modeling to identify other at-risk patients based on factors such as age, sex, the treating facility, and the length of stay, according to Eileen Scott, RN, BSN, project manager.

Patients identified to the program are assigned to RN case managers who have an average of 25 years experience, including 10 to 15 years as case managers. "They have the training and experience to engage members quickly in the process," she says.

The case managers are dedicated to the post-discharge outreach program and typically receive seven to eight referrals for new cases each day.

The predictive modeling data prioritizes the members based on their risk scores so the case managers can reach out to those at highest risk first, Scott says. The case managers try to reach the patients by telephone within two days of discharge and explain the program. The health plan’s goal is to start the telephonic outreach before patients see their physician for a follow-up visit to help fill the transition gap that occurs when patients are treated by a hospitalist in the hospital and then see their primary care provider, Scott says.

During the initial telephone call, the case managers perform an extensive assessment to determine the members’ understanding of their condition and their treatment plan, their support system, and any psycho-social issues. They ask if the members have filled their prescriptions and understand how to take them and make sure they have a follow-up appointment with their primary care physician or a specialist. "We work with them on questions to ask their provider and remind them to take their discharge instructions with them to their follow-up visit so their physician will know they have been in the hospital and what medications they were prescribed," Scott says.

The case managers have access to Cigna records and identify any other diagnoses or conditions and make sure patients are getting the necessary treatment for them. They look for gaps in care and encourage members to get the recommended tests and procedures. For instance, if a patient has been discharged after a myocardial infarction and also has diabetes, the case managers makes sure they have had a retinal exam, a foot check, and are checking their blood sugar regularly.

The case managers follow up with the members as needed to make sure they have seen their physicians and that the gaps in care have been filled.

"We don’t have a set time frame for them to follow patients, but the average time is 30 days to make sure they have seen their physician after discharge, are engaged in following their treatment plan, and can be discharged from the program," she says.

The case managers have a database of community organizations and other resources, such as medication assistance, they can use to get patients what they need to stay healthy.

If the case managers identify patients with extensive needs that go beyond outreach calls, they refer them to Cigna’s complex case management program or specialty disease management programs where they can be managed for longer periods of time.