Embedded CMs work with high-risk patients

A pilot project at Lutheran HealthCare in Brooklyn, NY, has embedded care managers in six of the health system’s family health centers to help patients who are frequent utilizers learn to manage their conditions, adopt healthy behaviors, and stay out of the hospital.

"We started this program using a two-year grant. The idea is to test the model and see the outcomes and to expand support to more patients depending on the kind of impact we have," says Jason Hyde, LMSW, M.Ed, assistant vice president for community case management at Lutheran HealthCare.

The initiative targets patients with 11 diagnoses: asthma, chronic obstructive pulmonary disease, diabetes, heart failure, hypertension, obesity, alcohol abuse and dependency, drug abuse and dependency, and mental illness. Eligible patients have at least one of the diagnoses and a combination of two or more visits to the hospital or the emergency department in a six-month period.

The majority of patients who are appropriate for the high-risk interventions are identified through a risk assessment based on information in the health system’s electronic health record. In addition, the care managers work closely with the inpatient case managers in the hospital to identify high-risk patients who need follow-up support. Each family health center holds pre-visit planning meetings when the treatment team can alert care managers to patients who don’t show up as high-risk but whom their providers believe need extra attention. "Our software is very good, but it’s not perfect. The providers know the patients better than anyone and can suggest patients to target," he says.

The 12 care managers, who have bachelor’s degrees and have gone through extensive training, call all patients treated by the health center, regardless of risk, within 25 hours of when they are discharged from the hospital. "We know that the period of time right after the discharge is risky for everyone," Hyde says.

The care managers ask how the patients are feeling, if they have questions or concerns, make sure they have their medication and that the patient has a follow-up appointment with the clinic. "Our goal is to make sure these patients are reconnected to primary care during the vulnerable time following discharge. We try to get high-risk patients into the clinic within 48 hours of discharge and make sure all others see the primary care provider within seven days of discharge," he says.

During the post-discharge phone calls, the care managers administer a 15-question care transition survey that asks patients about their experiences in the hospital and assesses their return to the community. Questions include whether patients were involved in their care plan, if they understand their care plan, and if they are following it at home. "We are looking for trends and areas where there are opportunities to improve and provide feedback to the inpatient team," he says.

The care managers receive lists each day of patients who are coming in for an appointment the next day and access the electronic medical record to see what gaps in care or other problems they may be having. For instance, patients with diabetes may have hemoglobin A1c levels that are too high, they may be overdue for an A1c test, or they may not have seen an ophthalmologist or had a diabetic food exam. The case managers contact at-risk patients for pre-visit planning and talk to them about gaps in care and other problems. "If a patient has had an appointment scheduled with a specialist but didn’t go, the care manager may find out that it’s a transportation issue and may need to set up transportation," he says. They ask the patients about their conditions, the support they are receiving, and any questions and concerns and share those with the patient’s provider.

Early each morning, the care team at the health center holds a huddle to discuss the patients scheduled for that day and their challenges. The team includes physicians, nurses, medical assistants, receptionists, and the care managers. Based on input from the team at the huddle and information in the electronic medical record, the care managers choose four or five patients to see in person while they are at the clinic.

When they see the patients, the care managers conduct a self-management assessment and develop a brief care plan with input from the patients. They go over the patients’ diagnosis, find out their health concerns and answer any questions they have. They share the information with the provider. Using motivational interviewing techniques, they collaborate with the patients to set two or three healthcare goals to work on and identify the support they have at home to help address any barriers to meeting the goals.

In addition, the care management team has developed a document called "My Self-Care Plan," which is completed during the self-assessment sessions and identifies the goals the patients have set, includes questions and concerns they want to share with their provider, and has a place where they can write the providers’ answers.

The care managers follow the patients for an additional four weeks after the care planning session. They contact them by telephone to find out if they are meeting their goals or if they need additional support. If the patients report not feeling well or have a lot of questions, the case managers connect them to the nurse or physician in the clinic.

"We want patients to learn to reach out to providers if they aren’t feeling well so the providers can intervene before their condition gets to the point that they end up in the hospital," he says.

When they’re not seeing patients, the care managers make outreach calls to patients who were discharged from the hospital and make pre-visit phone calls to the high-risk patients coming in the next day. The care managers typically have a caseload of about 50 patients in one stage or another at any one time.

In addition to the 12 care managers, the health system has embedded a nurse case manager and a social worker case manager at the busiest clinic, which treats a large portion of the highest-risk patients, many of whom have behavioral health disorders in addition to physical problems.

The care managers are assisted by five community health workers who live in the communities they serve. The community health workers offer hands-on support for the care managers in a variety of ways. For instance, if a high-risk patient misses an appointment and doesn’t answer the telephone, the community health worker goes to the patient’s home to find out what’s going on. If a patient can’t get to the clinic because of lack of transportation, the care manager may ask a community health worker to go to the patient’s home and give the patient a transit card for the bus or subway. Community health workers help patients get connected to services, such as housing support, free legal services, and public benefits. They escort patients with drug or alcohol problems to residential treatment programs and help with the intake.

"The community health workers undergo intensive training and supervision so they can interact with patients effectively and engage them in getting the treatment they need and managing their own health. They live in the community and are able to identify with the problems the patients face and quickly build rapport," Hyde says.