Reduce costs, improve outcomes with community case management
How to set up community CM at your facility
As reimbursement continues to shrink for Medicare patients and home health agencies, there is increasing concern about the fate of elderly and chronically ill patients. Seniors and others with complex comorbidities often are left to find their way through a complicated health care system with minimal guidance. The task can be daunting. Enter community case management, which increasingly is being considered a solution to the problems facing doctors and hospitals trying to care for this population with less help from the government.
"Community case management is a strategy [that] . . . assesses, plans, coordinates, implements, monitors, and evaluates the services and options needed to meet the health care needs of our patients in a high-quality, customer-focused, and cost-effective manner," explains Tracy Carver, RN, MSN, director of client services for the Internet health care site Canopy.com, in a white paper on the subject.
Carver designed and piloted a community case management program while doing her graduate studies and internship at Duke University in Durham, NC. "My experience was with an outreach program. I kept clinic hours at different sites and saw patients on a scheduled or walk-in basis. I would leave a form behind for patients to fill out if I wasn’t there, saying what the problem was and then follow up by phone or with an office visit."
Carver recalls how the program grew in the estimation of the physicians whose patients she helped and the savings this generated both for physicians and the hospital. "My biggest hurdle," she says, "was selling the docs on my role initially. The first couple of referrals were hard to get. But more and more they grew to depend on me. Eventually I started helping to screen their patients by looking at admission patterns, emergency room [ER] visits, and so forth. I could then tell the doctor which patients should be seen by me." She could spend the necessary time with the older, fragile diabetics and arthritic people and work with them to help them understand their medication regimen, their diets, and their other needs. And she says it didn’t take long for the physicians to realize how much time she was saving them and how much expense she was deflecting.
And how did Carver justify the expense of her program to Duke Medical Center? In fact, a hospital-based community case management program needn’t be a budget-killer. "There’s no new overhead for office space," Carver explains. "It’s not necessary to hire extra staff and incur other high-end expenses." In essence, her budget looked something like this:
- Salary for the case manager: benefits, taxes, etc.
- Equipment — personal: pager, cell phone, laptop computer.
- Equipment — office: phone, fax, printer, computer software, filing cabinet.
- Materials: paper, pens, file folders, computer disks (minimal — most records are computerized).
- Mileage.
Rebecca Zaseck, executive director of Area 2 Agency on the Aging in South Bend, IN, agrees that a budget for a community case management program need not be elaborate. "Case management hours are determined by the need for intervention and coordination and are billed to the funding source," she says. (This could be either the hospital, Medicare, Medicaid, or another payer.) "If a physical therapist or a nutritionist is needed, that is billed on its own. If home care is needed, that’s billed separately."
Zaseck recommends developing a care plan for patients to identify how much case management and how many ancillary services are needed. "Conduct an assessment to determine which services are needed — home health aide, meals, [physical therapy] — to keep the patient in the community. The amount of case management needed also is identified under the plan of care. If you work for a larger organization, you would include the costs for supervision, billing, and office space when building the budget."
Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, cautions that it is wise first to do an assessment of what’s currently available in the community and decide how far to take a case management program. For a hospital-based program, she suggests starting by selecting certain product lines. "Instead of going across the board with your plan, be selective. Start out just with obstetrics, for instance, or just teen pregnancy or psych patients."
She suggests emphasizing the cost benefit. "If you decide to provide some of those services after discharge instead of trying to push them all into a two or three-day hospital stay, you may avoid readmissions or additional doctor visits. After all, when a patient is hospitalized, sick, and medicated, it’s very difficult to absorb all the instructions and orders. It’s so much more effective to see the patient later, one on one, and go over those instructions slowly and personally. Then [the information] has a chance to sink in, and you stand a much better chance of avoiding the [ER] visits, readmissions, and calls to the doctor."
"Some people just look at start-up or maintenance costs, but not necessarily at the savings to the institution as a whole or the benefit to the patient." She encourages that any proposed budget should emphasize the value of one-on-one education and reduced visits back to the clinic.
Itemize the cost of an hour in the ER, a one-day hospital admission, or a visit to the doctor’s office, and compare it to the cost of four hours of a case manager’s time. It will illustrate an impressive difference. Once you’ve selected a product line and conducted a cost-benefit analysis, Homa-Lowry suggests putting together a simple budget. "But first look and see what resources are currently available through donations, specialty services, or volunteers," she says.
Carver agrees that volunteer services can be a huge benefit to a case management program. "Rather than allocate a medical director," she explains, "we got different doctors from different specialties to volunteer to help on an as-needed basis."
Though some might wonder at the reality of calling in those promises when the time comes, Carver says, "in truth, I probably only called upon each individual about four times a year." And she had so proven the value of her program to the doctors that they were happy to oblige. "I saved the docs a lot of time by serving as a patient advocate. It formed enormous goodwill between me and physicians, and they were happy to volunteer when I asked them to. The community case management program represented a big cost savings to doctors who might otherwise have needed to spend a half hour dealing with a Medicare patient."
In her white paper on the subject, Carver concludes that "the cost benefit of this communitywide case management program will show how specific case management interventions directly improve patient outcomes while reducing cost, decreasing inappropriate utilization, reducing admissions/readmissions, decreasing length of inpatient stay, improving quality of life, and increasing patient satisfaction."
[For more information, contact:
Tracy Carver, RN, MSN, Director of Client Services, Canopy.com, Chapel Hill, NC. Telephone: (800) 757-1354.
Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Consulting, Canton, MI. Telephone: (734) 459-9333.
Rebecca Zaseck, Executive Director, Area 2 Agency on Aging, South Bend, IN. Telephone: (219) 284-2644, ext. 252.]
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