CMs coordinate care for frequent utilizers

At the University of Michigan Health System, a team of specialized case managers coordinates services for patients who frequently visit the emergency department or are hospitalized, helping them get the resources they need to stay away from the hospital.

A small internal analysis showed that six months after receiving interventions from the complex care management team, hospitalizations for the 50 patients in the study dropped by 10% and emergency department use decreased by 8%, says Brent Williams, MD, MPH, associate professor of internal medicine and medical director for the University of Michigan Complex Care Management program.

The Complex Care team reviews discharge records each month to identify patients who are in the emergency department or hospital whose needs fall into at least three of six domains — complex medical needs, behavioral health issues including problems coping and substance abuse, psychiatric disorders, lack of physical resources such as housing or utilities, inability to afford medication, and lack of social support.

Patients who meet the criteria are assigned to a complex case manager. The program has seven complex care managers, who are masters-prepared nurses and social workers and are assisted by three patient care associates.

When patients are referred to the program, a complex case manager contacts them, performs a comprehensive assessment of their medical and psychosocial needs, and barriers to care. Based on the findings of the assessment and input from the practitioners who treat the patient, the case manager develops a plan to coordinate inpatient and outpatient treatment and whatever psychosocial services the patient may need.

Working with the emergency department team, primary care providers and specialists develop an individual treatment plan that can be used when each patient comes into the emergency department. "Rather than reacting to what the patient presents with, the emergency department team can mobilize a pre-existing coordinated treatment plan," he says.

For instance, many patients in the complex care program come to the emergency department because of pain. Before the program started, the emergency department physician would give them a prescription for pain medication and the patient would return as soon as the medication ran out. "Now, with complex care management, there is a plan in place and the emergency department staff gives patients the message that they need to go to their primary care physician for pain management," he says.

The complex care management program emphasizes communication across the continuum of care and with community organizations that can provide assistance. For instance, the team meets monthly with the emergency department team and collaborates on mobilizing resources for frequent utilizers. When patients continue to use the emergency department for non-emergent care, the complex case managers work with the patients’ primary care physicians and the patients themselves to find a solution.

Coordinating services

The complex case managers follow patients until they are stable and seek care in the appropriate setting, sometimes for a year or more. They accompany patients to their primary care and specialist visits and see them in the hospital, following up by telephone between visits. The case managers recently began visiting patients in their homes. "These patients have a large number of issues that are best understood and addressed when the case managers visit the homes and can see the conditions for themselves," Williams says.

Many patients in the program need mental health care as well as medical care. The complex case managers can coordinate between the two services to make sure that mental health practitioners are aware of the patient’s physical issues and that people providing medical care are aware of the patient’s mental health problems, he adds.

The key to the program’s success is that the case managers are able to coordinate services both inside and outside of the healthcare arena, Williams says. "The complex case managers provide a coordinated connection to social services and medical services. They know how to get an electronic benefits transfer card for people whose income is so low they may have to choose between buying food or medicine. They help patients access Medicaid-funded transportation and provide connections to a supportive housing group," he says.

The health system is still gathering data from the program but has received accolades from patients and their family members.

"We’ve gotten great reviews from patients who participate in confidential phone surveys. There have been no negative comments, and when we ask what we could do better, they suggest that their complex case manager move in next door or stop taking vacations," he says.