Consultant: CM must move to DM model
Gap between research, practices cited
With studies showing that 10% of patients are using 90% of the nation's health care resources, traditional case management must move to a disease management model, says Bob Whipple, RNC, CCM, CCS, MHA, a Boston-based senior management consultant with ACS Healthcare Solutions.
"Moving to a disease management model gives greater flexibility for meeting new challenges," Whipple adds. "It is the future of case management."
Disease management — preventive, diagnostic, and therapeutic services for types of patients considered at risk — is widely considered to be a more cost-effective approach to care, he points out. The Disease Management Association of America, Whipple notes, defines disease management as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant."
Those conditions, he continues, include these chronic diseases:
- congestive heart failure;
- coronary artery disease;
- chronic obstructive pulmonary disease;
- cystic fibrosis;
- multiple sclerosis.
Medical research has created a growing body of evidence on the most effective protocols for treating chronic diseases, Whipple notes. "However, reports by the Institute of Medicine and others have observed that a large gap often exists between such evidence-based treatment guidelines and current patterns of practice."
The case management model in place at most hospitals, he contends, is not adequately addressing the needs of the chronically ill.
Whipple points out a number of broad differences between case management and disease management, and elaborates on them as follows:
Characteristics of patient population.
Case management: People at high risk for costly, adverse medical events and poor health outcomes. Disease management: People diagnosed with a specific disease.
Methods for identifying patient.
Case management: Mailed questionnaires; data on use of hospitals and emergency departments; referrals by physicians using criteria to identify "high-risk" patients. Disease management: Data on presence of a particular diagnosis; prescription for certain drugs used to treat a disease; referrals by physicians who treat many patients with that disease.
Case management: No standardization of curriculum or educational materials; highly individualized. Disease management: Standardized curriculum and educational materials for a specific disease.
Reliance on evidence-based treatment guidelines.
Case management: Low. Disease management: High.
Reliance on protocols and standardization.
Case management: Low. Disease management: High.
Importance of using social support services.
Case management: High. Disease management: Low.
Importance of engaging family and caregivers.
Case management: High. Disease management:Low.
Reliance on care coordinator.
Case Management: High. Disease management: Medium.
A disease management program designed to improve health care quality and reduce medical expenses for those with complex or clinically advanced illnesses resulted in a 38% decrease in hospital admissions, reduced costs by more than $18,000 per patient, and garnered high satisfaction rates among 92% of the patients, according to a recent report in a prominent medical journal.
The report — on a study of Blue Shield of California HMO members — was published in the February 2007 edition of The American Journal of Managed Care, Whipple notes, and examined the program's impact on those with illnesses such as late-stage cancers or degenerative neurological conditions.
There are several reasons traditional treatment models fall short in the care of the chronically ill, he suggests, including the difficulty physicians have in keeping up with the latest developments in view of the tremendous growth in the number of medical studies.
In addition, Whipple says, patients with multiple medical conditions may receive care from many different physicians or providers at the same time, take a number of different drugs to treat their various conditions, and are often called upon to manage their own care at home.
As for what he calls the inadequacy of the case management model, Whipple says his experience as a consultant with a wide range of hospitals indicates that "there are lots of case managers and most are not certified."
"It's 'teach as you go,'" he adds. "There may be 15 or 20 case managers at a big hospital and not all have the same expertise." In many cases, Whipple says, "there is no way to ensure consistency, for example, on what they approve as inpatient or observation status.
"The big thing is case managers in the emergency department," he notes, "but some [facilities] have them, and they don't really know how to interact. They are floating between patients, and the physicians don't know who they are and sometimes resent them."
The best way to provide disease management in the hospital is to have advanced practice nurses make rounds with physicians, Whipple contends. "They are able to provide more interventions than a case manager.
"These nurse practitioners who round are actually involved with medical care, and determine whether a patient is compliant or not," he says. "They work with case managers to develop a discharge plan that really looks at the patient's needs. The big reason [chronically ill] patients get readmitted is lack of compliance."
Early identification important
Crucial to the development of an effective disease management program is early identification of patients with chronic conditions, Whipple says. "At a minimum, we need to learn to identify these patients on readmission. It's as important as getting the correct address and phone number."
That could mean instituting a different admission protocol, he notes, such as having a code to designate patients as "frequent fliers." That information should be communicated as soon as possible to case management staff, Whipple adds, so an appropriate treatment and education plan can be put in place.
What occurs more often than not in today's health care environment, Whipple says, is that patients — including the chronically ill — go through the care process under whatever designation they came in, whether it is correct or not.
"Often what happens is the patient comes in, especially if he or she is a frequent flier, sits in front of the registration person, and [the registrar] says, 'Any changes since the last time?' The patient says no, and [the employee] just automatically fills that in."
Whipple's experience doing assessments at all kinds of facilities — from 700-bed inner-city hospitals to 12-bed rural hospitals — has shown him that "admitters sometimes put patients on the floor that don't meet local medical review policies," Whipple says.
Physicians in the emergency department don't necessarily know anything about medical necessity, he points out, and residents in training at large teaching hospitals often want to admit a patient simply because many tests have been ordered on the person.
Adding clinical expertise to every part of the revenue cycle is one way to ensure that only patients who belong in the hospital are admitted, and that those who do need to be admitted receive the proper care, Whipple says. Someone in patient access, he adds, such as a preadmission coordinator, "needs to able to step in and say, 'This person doesn't meet medical necessity.'"
(Editor's note: Bob Whipple can be reached at Bob.Whipple@acs-hcs.com.)