Embedded case management provides growth opportunities
CMs can move beyond UM and discharge planning
New opportunities are on the horizon for case managers as the concept of embedding case managers in provider offices catches on.
"The role of embedded case manager offers a great opportunity for nurses and case managers to advance their practice and participate in a leading initiative," says Patricia Hines, PhD, RN, vice president of The Camden Group, a Los Angeles-based national healthcare consulting firm. Embedded case management is a relatively new phenomenon, that is evolving and increasing as insurers and healthcare providers collaborate to manage patients through the continuum of care, she adds.
"It's an exciting role for case managers to move beyond utilization review and discharge planning, and to become responsible for coordinating care as patients move through the continuum. They have the opportunity to get to know patients and follow them over time, rather than seeing them through just one episode of care," Hines says.
Randall Krakauer, MD, FACP, FACR, national Medicare medical director for Aetna, a Hartford, CT-based health plan, points out that embedded case managers enhance the value of healthcare by working collaboratively with physicians and other providers. Aetna began its embedded case management program in 2007, targeting its Medicare Advantage population and now has Provider Collaboration projects, many of which include embedded case managers in 57 sites in primary care and multi-specialty practices, integrated health systems, and with some independent physicians who are in close proximity to each other. (For details on Aetna's embedded case management program, see related article, below.)
The value in embedded case management is that it makes the care process longitudinal rather than episodic, Krakauer says. Embedded case management offers the opportunity for providers to manage care across the continuum, rather than just in the emergency department, the hospital, the skilled nursing facility, or in the home with home health services, he adds.
Many clinicians working as embedded case managers are in medical homes, Hines says. "As physicians have a high volume of chronically ill, high risk patients, they appreciate the role that case managers can perform in the physician office," she says.
Charlene Schlude, RN, CCM, director of care management for Capital District Physicians' Health Plan (CDPHP), an Albany, NY-based physician guided, not-for-profit health plan, points out that embedded case managers offer physicians assistance in enhancing their patients' understanding of their treatment plan, and identifying any barriers to adherence. That's where the embedded case managers can help by offering frequent interaction, and an individualized plan of care focused on the patient's unique needs. (For a look at CDPHP's embedded case management program, see related articles, below).
"We call it peeling the onion. When the embedded case managers talk to patients, they can find out what is underneath the surface that may make it challenging for them to manage their own health. They can take the time to identify social, financial, and emotional concerns that can impact their medical care," Schlude says.
Krakauer reports that when he introduces the concept of embedded case management to a new group of physicians, he points out that when doctors make rounds in the hospital and write orders, they have a high level of confidence that what they order will be done. "When they write a prescription or order consults for patients in their office, they have a low level of confidence that the patient is going to follow through. I tell them that while we can't create an inpatient situation in their office, case managers can do a great deal to increase adherence," Krakauer says.
According to Hines, the embedded case management role requires case managers with solid clinical experience who can work independently, are good at communicating with patients and multiple providers, and comfortable providing patient education. They need to be skilled, meeting patients at their level, and willing to be innovative and creative in order to help patients manage their conditions. "Most of all, to be an effective embedded case manager you have to have a passion for the work you do and love working with patients. It moves you to a whole new level of professionalism," she says.
Schlude says that when CDPHP hires case managers for its embedded case management program, it looks for people who have higher than average communication skills, broad clinical backgrounds, and a can-do attitude. "It's helpful if they have worked in a medical practice and understand the work flow of the office," Schlude says. The case managers must fit into the practice and become part of the team. They must be efficient and have the ability to work independently.
Tracy Langlais, RN, vice president of medical affairs and operations for CDPHP adds: "The case managers have to be able to change priorities quickly when they are embedded in a practice. They may have their day planned but physicians frequently bring patients who need a case management intervention into the office, and the case manager has to assess the patient quickly and intervene."
Embedded CMs partner with providers, patients Goal is to cut unneeded utilization The goal of embedded case management is to effectively manage patients at high risk for complications with their healthcare, and improve their quality of life. This will subsequently prevent unnecessary readmissions, admissions, and overutilization of the healthcare system, says Patricia Hines, PhD, RN, vice president of The Camden Group, a Los Angeles-based national healthcare consulting firm. "It's a way to put into practice the Institute of Healthcare Improvement's triple aim of better care, better health, and lower costs," she adds. Hines states that the embedded case management role has five principles that every case manager should follow:
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Embedded CMs solve problems for MDs They develop close relationships When a team from Capital District Physicians' Health Plan (CDPHP), based in Albany, NY, was introducing its embedded case management model to a new physician practice, solving a problem a physician had with a patient's adherence to her medication regime helped get buy-in for the program. The physician asked for help with a patient who had reached her Medicare drug coverage gap threshold and wasn't able to afford her $400 a month medication. The physician tried unsuccessfully to get samples from pharmacy representatives and was interested in other options. A case manager from CDPHP contacted the member and included her in a conference call to the Elderly Pharmaceutical Insurance Coverage (EPIC) funded through New York State. The woman qualified for coverage and two hours later was enrolled in the program, and was able to receive her medication with a $20 copay, until Medicare Part D started covering it again. "Embedded case managers have the opportunity to help physicians meet the needs of their patients with linkage to state-funded and community-based programs. In this case, the case manager consulted with our social worker who was familiar with the program," says Charlene Schlude, RN, CCM, director of case management for the not-for-profit health plan. The embedded case management program is part of CDPHP's enhanced primary care practice program in which the health plan, physicians and their staffs, work as a team to provide patient-centered care. In addition to the embedded case managers, the health plan also provides telephonic case management for high risk patients in the practice. (For details on how the program works, see related article, below) The health plan started its embedded case management program with a pilot in two practices in 2009, added a third in 2010, and now embeds case managers at 13 practices. The health plan is recruiting seven case managers with plans to expand the program further in 2012. Tracy Langlais, RN, vice president of medical affairs and operations for CDPHP, adds, "The examples of what our embedded case managers do are endless. They range from working with patients to follow their treatment plans and educating them on their disease and medication, to dealing with social issues and connecting patients to community resources. They are skilled at thinking out of the box to help patients overcome barriers to adherence." For example, a physician asked an embedded case manager to work with a man who was morbidly obese with severe diabetes. He was hospitalized for a significant infection, but he kept signing himself out of the hospital against medical advice. She found out that he lived alone with few friends and no family in the area, and he had no one to take care of his dog when he was in the hospital. The case manager found a groomer who would board the dog at no charge while the man received the necessary hospital treatment. "It's not just about the medical piece. It's about the social aspect in the patients' lives," Langlais says. The case managers gain information through remote access to all information in the health plan's system, and the electronic medical records in the practice to identify patients who could benefit from a case management intervention. Typically the embedded CDPHP case manager gets a list of patients coming into the practice that week and determines which ones need to be seen. They meet with patients who come into the office and follow-up by telephone. They encourage patients who need extra support to come back to the office when they don't have an appointment with the doctor. Whenever possible, the case manager steps into the room when the patient is waiting for the doctor for a quick chat to build more rapport. In addition to working closely with patients who have complex conditions, the embedded case managers make outreach calls to people with gaps in care who aren't necessarily chronically ill. Langlais reports that the health plan feels that the program is working because of comments from physicians and patients. "We are seeing higher engagement rates, and hearing about great successes from the embedded case management program. Overall, our enhanced primary care program has seen significant cost savings inclusive of case management. In 2012, we're going to conduct studies specific to the case management component," Langlais says. |
Pilot project benefits health plan Physicians, patients, CMs target chronic conditions When Capital District Physicians' Health Plan (CDPHP) began its pilot project, embedding case managers in physician offices in 2009, it was a challenge to get physicians to accept a health plan employee working in their practices. Now, physicians are requesting to participate in the program after hearing from their peers [about] how their patients' outcomes have improved, says Tracy Langlais, RN, vice president of medical affairs and operations for the physician-based not-for-profit health plan. Charlene Schlude, RN, CCM, director of case management, says that the health plan identifies practices where about 40% or more of patients are CDPHP members, then stratifies the practice's population to determine if there are a high number of members with chronic illnesses, or who are Medicare or Medicaid beneficiaries. "We put our case managers into practices where there is the highest need," she says. A team from CDPHP meets with the practice staff including the office manager and discusses how the embedded case manager initiative works, and if would be a good fit for the practice. Making space for an embedded case manager is a challenge for many practices that are already operating in cramped quarters. They have to rearrange their offices to give the case manager a prominent place, where he or she is easily accessible, and becomes part of the workflow within the practice. Langlais says, "At first when we began working with practices, they were willing to give our case manager space for only one of two days a week. Now they are willing to expand the number of days the nurses are in the practice, because of the successes we've seen." Depending on the size of the practice and availability of space, the case managers work in the practice two to four days a week. If the practice has a large number of chronically ill members, the case manager may be there four days a week. Some case managers are assigned to two practices. They all spend one day a week in the office making phone calls to members. The embedded case management supervisor visits the practices and guides the case manager in aligning his or her work around the specific goals of the practice. In addition, Schlude meets quarterly with the physicians and office managers from each practice to talk about how the program is working. |
Embedded case managers cut costs, improve quality Outcomes date from Aetna's embedded case management program targeting Medicare Advantage members indicates that the program decreases duplicate and unnecessary services, and improved health outcomes when compared to data from patients with unmanaged Medicare, according to Randall Krakauer, MD, FACP, FACR, national Medicare medical director for the Hartford, CT-based health plan. In 2009, Aetna's regular case management program achieved an overall 31% reduction in acute care days compared with unmanaged Medicare. In 2010, across all participating 20,000 Medicare Advantage members in these programs, the embedded case management program produced an additional 12% reduction in acute care days, he says. The embedded case management program builds on the success of Aetna's telephonic case management program, Krakauer says. Aetna began its embedded case management program in 2007, targeting its Medicare Advantage population. "Many people with Medicare have multiple chronic conditions and psycho-social barriers to adherence," he says. "There are considerable opportunities with this population to have an impact at the intersection of quality and cost." Aetna's embedded case managers work in medical groups, including primary care and multi-specialty practices, integrated health systems, and with some independent physicians whose offices are in close proximity to each other. For each practice an appropriate population to target in the program is chosen, and outcomes metrics are developed. The health plan has Provider Collaboration programs at 57 sites throughout the country with embedded case managers at many of these sites. Some case managers are not at the sites full time because of the number of Medicare Advantage members being served at the site. In the program, the health plan and providers work together for higher quality care, greater coordination of care, and to promote a better overall patient experience, Krakauer says. The embedded case managers identify patients to target by using Aetna's transaction records database as well as working with physicians and office staff to identify cases. "Sometimes the people in the office have a better perception of which patients need interventions than we do by looking at the data," Krakauer says. The case managers meet with the practice team to discuss the needs of patients targeted for the program and identify barriers to adherence. One goal is to reduce avoidable acute utilization, either an admission or a readmission to the hospital, which benefits both the patient and the health plan. "This is not just a cost issue, but it's also a quality issue," Krakauer says. "When a patient with heart failure is hospitalized for pulmonary edema, it's not just costly, but it also does further damage to the patient's already compromised heart." The embedded case managers become indispensible to the practices in which they work, he says. "Their responsibility is not just to deliver a case management program but to build a mutually supportive relationship with the physician and staff. The case managers are Aetna employees, paid by us, but they need to create the operational equivalent of being the case manager for the practice," Krakauer says. An embedded case management program is most effective when physicians and their staff come to the case manager when they identify patients with issues that have a case management opportunity and, in turn, receive information from the case managers that can help them provide care for the patients, he says. "We've found that when embedded case management works well, we get significant incremental value," Krakauer says. The case managers are permanently assigned to the physician office, and work there full time, except in practices where there is not a sufficient number of patients to justify a full-time case manager. They work with patients with complex conditions and chronic illnesses, to ensure that they receive the recommended tests and procedures, and follow their treatment plan. "The best outcome is avoiding unnecessary utilization," Krakauer says. "We're already reducing avoidable days with telephonic case management and are looking for measured, incremental reductions in addition to what we're already accomplishing." |
CMs collaborate with clinic counterpart As an Aetna case manager embedded in the Cleveland Clinic, Colleen Holland, RN, CM, shares an office and works as a team with a Cleveland Clinic case manager, to manage the care of at-risk patients covered by Aetna's Medicare Advantage plan, who have been recently discharged from the hospital. Referrals come from the acute care hospital case managers, as well as Aetna. For instance, a patient may not meet the criteria to trigger an Aetna case management referral, but has had a lengthy hospitalization. "When we get a referral, we look at the record to determine family dynamics and psycho-social issues that need to be addressed," Holland says. Both case managers work exclusively with Aetna Medicare Advantage members. When patients need community services, psycho-social support, or other assistance beyond telephone coaching, the two case managers work as a team to enroll the patient in Cleveland Clinic or Aetna programs that can help them manage their conditions, and avoid readmissions. "Both of our organizations have a lot of programs that can provide support to help patients stay healthy. Many times, the patients aren't aware of all the programs offered, or need help accessing them," she says. Holland doesn't usually see patients face-to-face but has extensive telephone contact with them. She contacts her patients two or three days after they get out of the hospital, makes sure they understand their medication and treatment plan, and that they have made a follow-up appointment with a physician. "We follow patients until we start to see the light at the end of the tunnel. It takes a lot of education and follow up calls to make sure that patients understand their treatment plan," she says. Medication reconciliation is a big issue with Medicare patients, many of whom are on multiple medications. "I pull the discharge sheet and go over the medications with them. Sometimes they were taking one before they were hospitalized, and were prescribed a similar medication in the hospital," she says. For example, she determined that one patient was taking two statins and was experiencing body aches, because large doses of statins break down muscles. Holland worked with the physician to discontinue one medication, and had blood work ordered a few days later to check on potential muscle breakdown and cardiac damage. "Usually, the duplicate medications are something benign, but it's dangerous for patients to take large amounts of some medication. We spend a lot of time on medication reconciliation so we can catch any duplication and keep the patient safe," she says. The case managers have the time to work with patients, and drill down to identify barriers to adherence that providers might miss. For example, the hospital referred a 96-year-old woman who didn't understand her treatment plan. Holland talked to a neighbor and determined that it was because the patient was hard of hearing. She arranged for the woman to stay in a skilled nursing facility until a better discharge plan could be developed, an intervention that prevented her from being readmitted. Holland has experience as a nurse in the emergency department, the intensive care unit, and in home care. She went through three months of training at Aetna before assuming her embedded case management duties. When she started her job, she collaborated with the Cleveland Clinic case manager to develop a plan for managing the care of patients. Holland reports that the two case managers working together have done a lot to help patients get the support they need to stay out of the hospital. She loves her job and recommends it for case managers who want to be on the cutting edge of healthcare. "Being an embedded case manager is a great job for someone who is motivated and can work independently." she says. |
"The role of embedded case manager offers a great opportunity for nurses and case managers to advance their practice and participate in a leading initiative," says Patricia Hines, PhD, RN, vice president of The Camden Group, a Los Angeles-based national healthcare consulting firm.
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