Critical Path Network

Disease management plan helps unfunded patients

Hospital system manages care of chronically ill

A disease management program implemented by nurse case managers helps chronically ill unfunded patients cared for by the North Broward Hospital District avoid hospitalizations and emergency room visits.

The hospital system started the program eight years ago to help alleviate the number of unfunded patients with chronic illnesses who were coming to the emergency department because they didn't have a primary care provider and were not getting the care they needed to keep their condition under control.

The program focuses on patients in the community who may have access issues, financial limitations, and who may never have been to a primary care provider.

"It's a win-win situation for everyone. We get these patients established with a doctor or a nurse practitioner and make sure they get the right care. The patients are healthier and we keep patients who have no ability to pay out of the hospital and the emergency room. Our strategy was to ensure a healthier community and it has worked," says Lori Kessler, BSW, MHSA, district manager for disease state management programs.

The program illustrates the benefit of educating people with chronic illnesses about their conditions and helping them stay healthy, Kessler points out.

"We did a cost-avoidance analysis and the program has paid for itself. People with chronic illnesses who don't take their medications, monitor their conditions, or keep their appointments with their primary care provider are likely to be hospitalized. By monitoring these chronic illnesses, we are improving the quality of life for these patients and cutting down their medical costs at the same time," she adds.

North Broward Hospital District, with headquarters in Fort Lauderdale, FL, has five acute-care facilities and 11 primary care sites. The nurse case managers are located at the primary care site and coordinate care for patients with asthma, hypertension, congestive heart failure, HIV-AIDS, breast cancer, and high-risk pregnancies.

Patients without insurance and those with Medicaid are eligible for the chronic illness program. There is no charge to the patient for participating in the program.

The nurse case managers work face-to-face with patients, meeting them at the doctor's office and acting as their liaison and advocate.

"The nurse may accompany patients to doctor visits and may suggest that patients show the doctor their blood sugar log or peak flow log or prompt them to give the doctor information about symptoms or to ask questions about the treatment plan," Kessler says.

They educate the patients to help them gain control of their disease, to understand their disease and its complications and comorbidities. They also teach them about the importance of adhering to their treatment plan, seeing their physician regularly, and to act before their symptoms become severe enough to warrant hospitalization or an emergency department visit.

They teach their patients the importance of receiving recommended tests and procedures, such as eye examinations for diabetics. They call to remind patients of physician appointments and to get their medications filled.

"We take a team approach to managing care. We work closely with the providers to make sure that the patients follow the treatment plan. The providers are happy that our nurse case managers are there on site to provide patient education, like teaching the patients how to use a glucometer," she says.

About 60% of the patients are referred by the hospitals in the North Broward District. The rest are referred by the clinics and community agencies.

When patients are referred to the program, a case manager examines their records in the hospital system's electronic medical record to get clinical details, then calls the patient and develops a plan for managing the patient's condition.

Finding patients' medical homes

When a patient is referred to the program, the nurse case managers find out if the patient has a medical home. If patients have been hospitalized or visited the emergency department and don't have a medical home, the case managers help them find a physician at a convenient location and ensure that they get the follow-up care they need.

The nurses stratify the patients based on psychosocial issues, utilization of health care resources, and clinical indicators.

In addition to seeing them in the clinic, the nurse case managers contact the patients at regular intervals, depending on the patient's risk for a decline in health status and other factors.

"Even if a patient has a good control of her medical [condition] but may have just lost her husband, the case manager will call more frequently. Or, if someone has started a new medication, the nurse will call to make sure everything is going well," she says.

The nurse case managers slowly build relationships with their patients, working on the issues that are most important to the patient as they educate the patient about their disease and the importance of preventive care while being culturally sensitive to the patient.

"Sometimes the patient presents to the case manager and all she can think about is how bad her eyes have gotten. Before we can move into any other real [area] of her care, we get her eyes checked. This gives the nurse a starting point and over time she can expand to other health care problems or health-related issues the patient needs to address," she says.

Sometimes patients are in denial because they don't have symptoms and the case manager must educate them on the disease. "They may have hypertension but they don't feel bad or have symptoms until they have the first stroke. If they have no funds, they can't go for preventive care," she says.

They assess the patients' needs and work with community agencies to make sure eligible patients are receiving food stamps and other needed resources.

The case managers are assigned to patients by location, rather than disease.

"So many of these patients have comorbidities so it's better to have one nurse coordinating the care for all of the conditions. The nurses can always call on others for help and often co-manage patients with complicated diseases like HIV or cardiovascular disease," Kessler says.

Because the patient population is culturally diverse, most of the staff speak more than one language, including Spanish, Creole, and French.

In addition to conducting one-on-one education, the nurse case managers in the program arrange regular group sessions for patients with a particular disease, often partnering with other resources in the community. For example, the program organizes "Foot Days" and invites all the patients with diabetes to participate.

Kessler brings in a podiatrist from Nova University to help with the education sessions and to conduct foot examinations. She gives the participants small mirrors and encourages them to check their feet regularly.

"We get the patients educated and their feet checked for free and the Nova University students get good experience," she says.

(For more information, contact Lori Kessler, BSW, MHSA, district manager for disease state management programs, North Broward Hospital District, e-mail: lkessler@nbhd.org.)