Critial Path Network
Hospital’s DM program cuts admissions, ED visits
Program saved $5 for every $1 spent
When Jackson Health System in Miami started its first hospital-based disease management program in 1995, the case management department was able to show that the hospital saved $5 for every dollar the hospital spent on case managers in the disease management program.
The first disease management program was for patients with diabetes. Now, approximately 30 case managers provide disease management for patients with a range of diagnoses including asthma, congestive heart failure, HIV-AIDS, obesity, hypertension, an employee wellness program, and behavioral health, in addition to the original diabetes program.
The goal of the hospital’s disease management program is to support patients and their providers regarding their care to avoid hospital readmissions and visits to the emergency department (ED), according to Abbe Bendell, RN, CNS, MBA, CCM, vice president for care management, quality, and patient safety at Jackson Health System.
The hospital identifies patients with the potential for the disease management program by looking for chronically ill patients who are admitted frequently or who make frequent visits to the ED.
If a patient comes in with one of the diagnoses covered by the disease management program, the inpatient case manager alerts the outpatient disease management case manager to follow them on the outpatient side.
In some cases, the disease management process starts when the patient is in the ED. The ED case managers can refer patients directly to the disease management program, even if they are treated as an outpatient, ultimately avoiding an admission, Bendell says.
Depending on the diagnoses and the seriousness of the patient’s condition, the disease management case managers may visit them in the hospital or be in touch by telephone after discharge.
The case managers offer their services to the patients, conduct an initial assessment, and arrange follow-up contact on the outpatient side.
"Even if the patients don’t want a care manager who is closely in touch with them, we continue to monitor them from a distance to make sure they are getting their prescriptions filled and getting to their follow-up doctor’s appointments," Bendell says.
The case managers who work in disease management visit the hospital’s primary care sites at least once a week and work with the physicians and staff there to give the patient additional support.
They follow up by telephone to make sure the patients are following their treatment plan and periodically visit them in the clinic for a face-to-face visit. If the disease management case managers feel it’s needed, they can visit the patient at their home or at another location.
Based on the patient’s condition, the follow-up may be as often as once a week but, if the patient is stable, it may be as little as one a month or even less frequently.
"The frequency of the contact depends on the diagnosis and the case manager’s ability to be in touch with the patient," Bendell says.
The frequency with which the case managers meet the patients in the clinic depends on the severity of the patient’s disease and how frequently they are see in the clinic.
They coordinate with the treatment team to identify psychosocial issues that affect the disease process and any barriers to care.
When they visit patients in the clinic, the case managers may go into the treatment room with the patient, if the patient requests it, or visit with the patient after he or she has seen the doctor. They also talk to patients about the treatment plan, making sure they are taking their medication, exercising, and following an appropriate diet.
"They make sure that the patient has actually purchased the prescribed medicine. They talk with them to identify any problems at home, work, or school and look for any barriers to following the treatment plan," Bendell says.
They make sure the patient understood what the doctor said and identify whether he or she has additional educational needs.
The case managers look for barriers that might prevent the patient from accomplishing what the physician recommended and help him or her overcome the barriers.
"Sometimes the physicians give medication to patients that don’t react well with the patient’s system. More times than not, the patient won’t tell the doctor this, and it’s usually the case manager who figures it out," Bendell explains.
"Our goal is to help the client come to terms with his or her disease and to be able to manage it. We work to transition them back to their primary care sites without support from the case manager, although either the patient or the physician can call the case manager for support if the need arises," she says.
With some of the populations, the case managers may follow the patients for six months or a year and then refer them back to the primary care physician with little support. Other patients, such as those with HIV-AIDS, may require long-time disease management at frequent intervals.
A comprehensive educational program for patients with chronic diseases is a fundamental part of Jackson Health System’s disease management programs.
The disease management case managers go into the community and conduct classes about chronic diseases in multiple languages. The educational program content was developed from best practices, such as the American Diabetes Association’s recommended content for diabetes education classes.
The health system has created standardized educational materials that are used across the entire continuum of care.
For some patients, the educational process begins in the emergency department. The emergency department case managers have access to starter kits with information about the disease.
When a case manager determines that a patient needs more education following a clinic visit, he or she may present the education one-on-one on the spot or set it up for the patient to go to a class.
"Our education doesn’t replace the chronic disease education that comes from the clinician. It’s an overlay to the primary care physician’s educational efforts. Most people need to be taught more than one time," Bendell says.
The hospital’s disease management case managers are cross-trained to manage more than one disease, but the case managers with the most expertise in a particular disease act as a resource for the rest of the staff.
The health system’s medical directors for each disease are another resource.
"When case managers have a concern about a patient and the care that is being provided, they discuss the case with the medical director for that disease. In some cases, the medical director gets together with the primary care physician on a consultation and may recommend a change in the treatment plan," she says.
When Jackson Health System in Miami started its first hospital-based disease management program in 1995, the case management department was able to show that the hospital saved $5 for every dollar the hospital spent on case managers in the disease management program.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content