Physician practice CMs manage through continuum
Team approach is key to success
When Hilja Bilodeau, RN, CCM, set up the case management department for Harbor Medical Associates five years ago, the Southeast Massachusetts-based physician practice was the first in its area to have internal case managers.
"Physician case management is still new, although it has developed within the past five years," says Bilodeau, director of case management for the 34-physician practice.
Setting up case management for a physician group was a hard sell at first, Bilodeau says. Physicians were wary about having someone come into the office and put plans of care in place, seeing it as another layer of bureaucracy to deal with, she adds.
But that’s all changed.
"They have realized the benefits, and we work collaboratively as a team. They think it’s great to have another person help with the difficult situations," she says.
Bilodeau attributes the success of the program to a team approach, collaborating with physicians and other case managers every step of the way.
"One of our successes is buy-in from the physicians and hospitals. The hospital case managers work closely with us, and we emphasize that it’s a team approach. Patients pick up that relationship, and we are very successful in getting the patients to the best place they need to be," she says.
Bilodeau was a case manager for managed care companies for more than 25 years, having worked with major insurance companies and a large HMO before joining Secure Horizons to set up its capitated program.
"We set up our own mini-HMO and put together a process that met standards for the insurance company, as well as for the Medicare Risk population," Bilodeau says.
As a result, Secure Horizons, the Medicare Risk section of Harbor Medical Associates, was the first delegated physician group on the south shore of Massachusetts.
The physician practice will become fully delegated for a major commercial insurer early this year. "We are a physician-based case management program, employed by the physician organization," Bilodeau says. The Harbor Medical case managers often work with the hospital case manager and the home care case manager, as well as working closely with the patients and their families.
"We know their families. We don’t just manage the insurance and payment aspect. We go beyond that and work with the social aspects, hooking patients up with the appropriate resources," says Linda Connell, RN, a case manager for the Medicare Risk population.The physician case managers make rounds daily in the hospital and form collaborative plans of care with the hospital and insurance case managers.
They see patients at the physician offices, act as advocates for the patients should they need ancillary services, and work closely with the Wellness Center, a collaborative effort at disease management between the physician group, CVS Pharmacy, and Pfizer Health Care Solutions.
For instance, when a patient was having difficulty paying for his cholesterol medicine, Connell worked with the Wellness Center to locate community resources such as the Massachusetts Advantage Pharmacy Program and contact drug representatives to take advantage of their programs to provide medicine for indigent patients.
"We focus on the patient as a whole and follow them through the continuum. We are a great resource for any of the services not covered under the insurance plan," Connell says.
Throughout the patient’s hospitalization, the case manager makes sure the patient is making the expected progress and meets with the family and patient regularly to reassess the goals. "We may readjust the goals three to four times," she adds.
If the patient is being discharged with home health services, the case manager meets with the Visiting Nurse Association, then calls the patient at home to make sure the plan of care and goals are being met and helps the family get in touch with community agencies, such as Meals on Wheels, to provide additional care for the patient.
If the patient needs long-term care beyond what Medicare covers, the case managers help them contact a social worker to help apply for Medicare. The Harbor Medical case managers are notified when patients are admitted to the emergency room and help the hospital case manager expedite getting patients to the appropriate venue of care.
"No one is slipping through the cracks. We are on-call 24 hours a day, 365 days a year," Bilodeau says.
Before Harbor Medical Associates set up its case management system, patients often had a case manager in an insurance company but the case managers were not designated for specific patients. For instance, the insurance case manager in the hospital managed acute and subacute care, but handed the patient off to another case manager that managed home care.
"There were different people managing the patient in different parts of the community. In our role, we’re able to manage the patients through the continuum, including wellness services," Connell says.
Secure Horizons has 25 physicians fully delegated for the Medicare Risk population. Two case managers serve that population to meet the requirement of one case manager for every 1,500 patients.
Each of the two case managers for the Medicare Risk patient is assigned patients from specific physicians. The hospital case managers work the same way, working with patients from specific physicians. Each physician-based case manager works with a particular hospital case manager.
"After we round at the hospital, we collaborate on what needs to be done and coordinate with them and with the payer case managers during the day," Connell says.
Harbor Medical Associates’ commercial population of about 9,000 patients is not fully delegated and is managed by one case manager.
However, the commercial population is much younger and does not require as much management. In fact most of the work with the younger population is educating them about their managed care policy, where insurance allows them to go, and what their coverage is, Bilodeau says.
"We do see the commercial patients in the hospital and are very involved in outpatient services, such as physical therapy," she says.
The commercial case managers see the physician case managers as a great front-line to the physicians.
"I go right to the physicians and talk to them about care. We really do collaborate on a daily basis. Before I leave the hospital, I talk to the commercial case managers and discuss the plans of care for all the patients," Bilodeau says.
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