CMs coordinate all their clients' health care needs
DM, CM, home visits are part of the program
At Crescent PPO, case managers follow their clients through the continuum, helping them with all of their needs, whether it's disease management, case management, education about a chronic condition, or help navigating the health care system.
"People do truly want to get better, and when a member of the health care team cares that they succeed, it does make a difference. Since I've been working with my clients, I have seen diabetics' hemoglobin A1Cs drop from 13 to six and below. I've seen people quit smoking and their cholesterol drop. Claims for the employers have dropped. It's all a matter of providing individual care," says Teresa Fugate, RN, BBA, CPHQ, CCM, a case manager with the Asheville, NC not-for-profit PPO.
The PPO provides health management and pharmacy services for self-insured clients including hospitals and other employers in western North Carolina.
"Our goals are to help people improve their health status to prevent them from getting chronic disease, reduce chronically ill patients' risk of complications, and/or prevent the progression of the disease," Fugate says.
The company uses claims data to identify the high-risk areas for health management among the employer groups, then offers programming for a comprehensive case management program, Fugate says.
The PPO's case managers are assigned by employer group and coordinate all of the employees' needs, including conducting educational sessions at the work site and visiting seriously ill patients in the hospital or their homes.
"I manage the care for a group of patients, regardless of their diagnosis. For each group of enrollees, I also provide education and work to help them improve their health as well as managing their care as long as needed," Fugate says.
Fugate visits the employer sites and conducts educational sessions, such as smoking cessation, diabetes education, or seminars on controlling hypertension or high cholesterol.
Many of the employers offer incentives for their employees to participate in a disease management program. For instance, the employer may offer diabetes medication with no co-pay if employees with diabetes attend classes on diabetes management.
"The individuals in the disease management program also become my case management patients. We don't just drop in and educate them. We keep up with them and follow them through the continuum," she says.
Fugate works with five employer groups and manages the care of all their employees. She gets to know her clients as individuals and makes sure they get the services they need in a timely manner and that they have all the information and tools they need to follow their treatment plan.
"Nobody wants to be sick. Patients want to get well, but they have to have the right information and education. You can't talk to them about their disease for 15 minutes and expect them to figure it out. Nonmedical people are not always savvy enough to be able to search out reliable information on the Internet," Fugate says.
Fugate leads her clients through the often-bewildering health care system, making sure that that they receive their benefits in a smooth and timely manner.
"I tell the patients that I'll take care of their hassles for them. All they have to do is call me if they are having problems, and I'll smooth the way," she says.
If her clients have questions about their claims, Fugate will go over the paperwork with them and answer any questions they may have. "Crescent's other case managers and I are supported by a first-rate client service team at the company's Asheville office. Even though the company does not administer claims, the case managers and client service personnel work together to help clients resolve claims issues and our efforts have been very successful," she says.
She works with the pharmacy to make sure the client's medications are accurate and that they are not taking medications that could interact with each other.
If patients are having problems getting their prescriptions preauthorized, all they have to do is call Fugate and she gets it handled, often by the Crescent pharmacy benefit customer service team.
If they are required to have a procedure or visit a specialist, Fugate contacts the physician's office to ensure that it has been pre-certified.
"Our philosophy at Crescent is that providing cost-effective quality care doesn't mean limiting certification. We'd prefer that a patient have an MRI on Wednesday rather than ending up in the hospital the next Friday," she says.
If a patient is going to have chemotherapy and the employer has a contract with a particular infusion company, Fugate makes sure the physician refers the patient to that company for treatment.
"I follow up and make sure they are getting the treatment they need. If I ever have a question about the care a patient is getting, I bring in the Crescent medical director to talk with the physician," she says.
Fugate and the other case managers at Crescent PPO take a proactive approach to managing the care of their clients. They are notified whenever a pre-certification request comes in for a procedure that may indicate that one of their clients is at high risk.
For instance, Fugate may receive information that one of her clients is having a biopsy to detect possible breast cancer.
When the results are back, she calls the patient and introduces herself.
"I ask for the results, and if they are clear, I celebrate with them. If they are not, I explain what case management is all about and start to help the patient navigate the health care system," she says.
Fugate visits patients who need her services in the hospital and makes home visits to patients with serious illnesses, such as multiple sclerosis or cancer.
"I sit down with them and go over their condition and the treatment plan so they will understand their illness. I take educational materials and give them a list of web sites they can consult," she says.
For instance, when one client with cancer didn't understand her treatment plan, Fugate requested the physician notes and reviewed what the physician had told the patient. She talked with the doctor to make sure she was on the right track, then wrote down instructions in detail. Next, she went to the patient's home and spent more than an hour going over the instructions.
The woman had been forgetting to take her medicines and making other mistakes in caring for herself. After Fugate helped her understand, the patient became compliant. Her doctor told her that she had done better than other patients who had received the same treatment. She was less sick than most patients and was able to go back to work during treatment, Fugate says.
"My relationship with my patients is very rewarding. I am in awe of the things they are going through and how they are overcoming the obstacles. I do whatever I can for them to make it easier," she says.
Fugate goes to employers' health fairs and lets the employees know that she is available to help. She works with the organization's human resources department to get the word out about her services.
When Fugate receives a referral, she calls the patient, then follows up with a letter and her card.
"I encourage the patients to call me. They don't have to go through a main number. They can get to me directly on my cell phone," she says.
Crescent PPO encourages the members to be proactive about their health care and to contact the PPO whenever they have problems or questions about their health.
"People don't necessarily understand what their responsibility is. They think it's their doctor's problem to make them better. We help them understand their role in managing their health and support them as they make changes," she says.