Medical group CMs coordinate care

Patients to get care they need to avoid readmissions

At Sharp Community Medical Group, case managers work in a variety of settings to make sure that patients are getting the care they need in a timely manner and to ensure continuity of care as patients move through the continuum.

The San Diego-based IPA has in-house case managers who provide post-acute and complex case management as well as case managers who work with the hospitalists in local hospitals.

The physician group's disease case managers provide disease management to patients with diabetes, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease.

"We have case managers throughout the continuum to make sure the patients are getting the care they need to prevent readmissions," says Karla Ascencio, RN, director of health services for Sharp Community Medical Group.

John Jenrette, MD, the medical group's chief medical officer and CEO, is a firm believer in case management, says Patti Derouin-Genel, RN, manager for Sharp Community Medical Group

"Dr. Jenrette feels that nurses have a vital role in coordinating care. This is a very forward-thinking company regarding the benefits of a strong case management program," says Derouin-Genel.

The physician practice has recently developed a case management program in local skilled nursing facilities. That program is staffed by three nurses and two clinical resource coordinators.

The nurses attend case conferences and conduct telephonic review, following the patients through physical therapy, occupational therapy, and speech therapy. They track the number of days to ensure that the stay meets Medicare requirements and follow the patients through any post-discharge care.

"It's a nice continuum. The patients are followed by the hospitalist team and the ambulatory care managers at Sharp Community Medical Group's offices as well as a skilled nursing team. We provide case management at every level of care," Ascencio says.

If a patient who is part of the Sharp system goes to an out-of-network facility, a case manager travels to the facility and manages the patient's care until he or she is stable enough to be transferred to a Sharp facility.

The case managers in the Sharp Community Medical Group refer patients to each other as needed. For instance, if a patient in the hospital has diabetes and isn't already in Sharp's chronic disease management program, the hospitalist case manager refers them.

The inpatient case managers refer eligible patients to case managers within the medical group who provide post-acute case management, complex catastrophic case management, and disease management.

"We integrate all our case management efforts including the chronic disease management program, the telephonic case managers who follow the patients after discharge, and the hospital-based case managers," Ascencio says.

The medical group's clinical resource coordinators call each patient within 48 hours of discharge to ensure that all their needs have been met. This equals about 650 post-discharge calls a month.

They ask several critical questions, depending on the patient's particular situation. These include: Have you made a follow-up appointment? Did you fill your medication prescription? Did your durable medical equipment arrive?

If the patient has questions about medication or wound care or what appears to be a clinical manifestation, the call is immediately referred to one of Sharp's acute care managers who follows up with the patient and contacts the primary care physician or the home health or equipment agency as needed.

If the patients haven't made an appointment for a follow-up visit, the clinical resource coordinators help them do so.

"Ensuring that patients have a follow-up visit with their primary care providers is vital to our success. Many patients who see their primary care doctor after discharge end up back in the hospital," Ascencio says.