Patient access has role in disease management

ID chronic cases upfront, consultant says

The great majority of U.S. health care dollars are spent supporting the chronically ill, yet the traditional focus of hospital care is on the "episode of illness," notes Bob Whipple, RNC, CCM, CCS, MHA, a Boston-based senior management consultant with ACS Healthcare Solutions.

"In other words, chronically ill patients get sick, go to the hospital, and are discharged without their [ongoing] medical needs being addressed," Whipple contends. "This results in multiple admissions."

Ten percent of the patients are using 90% of the health care resources, he adds. "Something has to be done to decrease the cost of becoming sick and then sicker."

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, Whipple says. The Disease Management Association of America (DMAA), he 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."

Full-service disease management, the DMAA states, must have six components:

  • population identification processes;
  • evidence-based practice guidelines;
  • collaborative practice models to include physician and support-services providers;
  • patient self-management education;
  • process and outcomes measurement, evaluation, and management;
  • routine reporting/feedback loop including the patient, physician, health plan, ancillary providers, and practice profiling.

Key to moving forward with a disease management model, he says, is increased clinical awareness and expertise, not only on the treatment side, but throughout the revenue cycle.

Patient access staff have an important role to play in the effort, Whipple suggests. "Most hospitals are not able to really identify who those [chronically ill] patients are.

It's critical to find out who they are and treat them in a different way. That should start upfront with the possibility of admitters being able to identify these patients when they come through the door."

Diseases commonly considered to be under the domain of disease management include the following:

  • congestive heart failure;
  • asthma;
  • cancer;
  • coronary artery disease;
  • chronic obstructive pulmonary disease;
  • cystic fbrosis;
  • depression;
  • diabetes;
  • hypertension;
  • lupus;
  • multiple sclerosis.

"At a minimum, we need to learn to identify these patients on readmission," Whipple says. "It's as important as getting the correct address and phone number." That could mean instituting a different protocol, he notes, such as having a code to designate patients as "frequent flyers."

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, he 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 flyer, 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."

His 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 (LMRP)," Whipple says.

Physicians in the emergency department (ED) 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.'"

"If there is a strong person on the front end, reviewing every patient who goes to a bed, things are likely to be OK on the back end," he adds, but ideally there is also a clinical component in the billing area.

Whipple recalls a time earlier in his career when he was one of two registered nurses working in the billing department of a big-city hospital. "I was busy all day just answering questions. I remember thinking, 'If I wasn't here, the amount of money lost would be incredible.' We found mistakes all week long."

Case management deficiency cited

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 number of medical studies has grown tremendously in recent years, making it ever harder for physicians to keep up with the latest developments," he adds.

The case management model in place at most hospitals is not adequately addressing the needs of the chronically ill, Whipple contends. "There are lots of case managers and most are not certified. It's 'teach as you go.' There may be 15 or 20 case managers at a big hospital and not all have the same expertise."

In many cases, "there is no way to ensure consistency, for example, on what they approve as inpatient or observation status," he says. "The big thing is having case managers in the ED. Some [facilities] have them, but 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, Whipple says, is to have advanced practice nurses who round with physicians and 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. They work with case managers to develop a discharge plan that really looks at the patient's needs."

(Editor's note: Bob Whipple can be reached at