Team approach helps high-utilization patients

Care management is an interdisciplinary plan

A team approach to managing patients who are likely to be high utilizers of health care resources has paid off at HealthCare Partners, a large multispecialty medical group in Los Angeles County serving more than 450,000 patients.

At HealthCare Partners, the interdisciplinary care management team includes physicians, a physician assistant, RN case managers, social workers, and their case management coordinators who make telephone calls and home visits when warranted to check on patients.

"In our interdisciplinary practice, we extend our care management team to external providers, too. If we’ve got a patient in the hospice or home health, their providers become part of the care team," says Ellen Aliberti, BSN, PHN, MS, CCM, regional director of care management for HealthCare Partners.

The team focuses on patients who are frequent utilizers of the emergency department or one of the medical group’s urgent care centers.

The organization has identified five categories of patients targeted for management:

  • the medically ill;
  • the terminally ill who require end-of-life care;
  • drug seekers;
  • somaticizers — patients who have a lot of vague symptoms, such as pain, headaches, and abdominal pain, and receive frequent referrals to specialists for further tests;
  • the frail elderly.

Patients in all five categories have psychosocial stressors that can impede their recovery or exacerbate their conditions, and they need a multidisciplinary approach to care, Aliberti adds.

Patients are targeted through referral data by physicians and other members of the interdisciplinary team who may come in contact with them.

The team educates physicians about the characteristics of each group and what patients they should refer to the care management team.

Because HealthCare Partners deals primarily with globally capitated patients, the primary care physician is the gatekeeper for referrals. This gives the organization the advantage of knowing what services the patients are receiving.

When a patient is identified for care management, the case managers do an assessment to find out what is driving the patient’s utilization. This includes a thorough record review, and interviews with the specialist and primary care physician to find out what’s going on with the patient’s care.

After the assessment is complete, the care manager meets with the physician and the patient or family members to come up with a care plan.

The team holds a weekly case conference to discuss the patients and decide what approach to take. Participants go over the pressing cases and brainstorm what the next steps should be.

"With finite resources, we have to home in on the ones we can affect the most," Aliberti adds.

The team also examines authorization data to see if the care plan has effectively improved the care.

In some cases, if a patient has continued to make regular trips to the emergency department, the team will decide that the patient should been seen more frequently by the primary care physician.

"We also use the case conference time to brainstorm with the primary care physicians and to educate them about what’s going on with the patient on the interventions, such as social work, that are not really in the physician’s purview," she says.

Managing the care of patients should be a partnership between the care manager and the physician, Aliberti says.

Patients may have significant psychosocial stressors and behavioral health problems that the physician may not be addressing. That’s when other team members become critical to a comprehensive care plan for the patient.

"It’s important to have an interdisciplinary approach between the nurse-case managers, social workers, and the physician," she says.

At HealthCare Partners, the social worker acts as a consultant to give direction or provide clarity when necessary. For instance, if the physician is trying to manage the care without involving the case manager, the social worker helps provide resources.

HealthCare Partners has a physician assistant (PA) on the care management team who can make house calls if they are warranted.

"If we’ve got a concern because the patient has not seen the primary care physician but has been in the emergency room several times, the PA makes a home visit," Aliberti says.

Identifying and managing high-risk patients takes an interdisciplinary model in which all team members are alert to the characterization of the targeted patients, Aliberti says.

"You need everybody’s eyes and ears and their vigilance to identify high-risk patients. For example, a frequent emergency room user will not be identified through claims review until you have six or eight months of data," she adds.

Although HealthCare Partners applies an interdisciplinary approach to care, the organization is working toward all interdisciplinary team members becoming equipped with a core set of skills. For instance, if a patient needs Meals on Wheels, the care manager can arrange it, rather than passing it off to the social worker.

The social worker serves as a consultant to other case managers but also carries his or her own primary caseload. The team uses ambulatory care coordinators (nonlicensed paraprofessional staff) who support case management efforts by performing telephonic screening to check on patients and caregivers.

The coordinator has a scripted set of questions and notifies the care managers if a patient sounds like he or she may be having problems.

"We are trying to work toward a delicate balance of specific and generic expertise to maximize the skills of the team," Aliberti says.

HealthCare Partners is moving toward a two-pronged approach in which individual primary care physicians initially would be notified of high-risk patients and would apply interventions for changing utilization patterns.

"If the patients continue to come back into the emergency room or show other signs of inappropriate utilization, then they will be directed toward a more interdisciplinary approach to managing their needs," she says.