Community case managers help patients stay healthy

Program targets at-risk geriatric patients

At- risk geriatric patients with multiple comorbidities and health-related issues are staying healthier and out of the hospital thanks to face-to-face visits from nurse case managers from the Moses Cone Health Med-Link Community Care Management program.

Med-Link provides a geriatric community case management program for Blue Cross' Blue Medicare members in the metropolitan Greensboro, NC, area. A new case management program for employees and dependents covered by Moses Cone Health System's self-insured health plan was added two years ago.

All Med-Link services are free to patients. Blue Medicare pays a per-member per-month fee, and the Moses Cone Health plan pays a flat fee for the employee Med-Link program.

"Patient satisfaction for both programs is greater than 95%, and the program is well known and highly regarded by the local medical community. Med-Link nurses get great satisfaction in knowing they are providing a valuable service and really making a difference in the day-to-day well-being of patients," says Elizabeth Westwater, MedLink community care manager director for the Moses Cone health system.

The Med-Link program was developed 10 years ago to provide community case management services for the HMO patients contracted to the Greensboro HealthCare Network, a joint venture between the Moses Cone Health System and Eagle Physicians. Greensboro HealthCare Network is a for-profit organization with risk contracts for Medicare patients.

"Our geriatric community case management services help keep people living at home as long as possible by helping them cope with the medical and psychosocial issues related to aging. We provide medical monitoring, education, support, and advocacy to maintain health, independence, and quality of life," Westwater says.

Patients enrolled in the program tend to stop bouncing in and out of the hospital, Westwater reports.

"However, it's hard to measure outcomes because the needs of these patients are so intense, and it's a chronically declining population," she adds.

The case managers are registered nurses with experience in working with community-based patients. Most have earned their CCM certification. They visit patients in their homes and provide advocacy and support to prevent and manage conditions and situations that place patients at risk for complex medical problems, Westwater says.

Referrals come from physician offices, from the HMO, and by self-referral. In addition, the program has a nurse case manager who visits hospitals in the system to identify patients who are eligible for the program and gets permission for a Med-Link case manager to follow up with them after discharge from home to assess their needs.

Patients who are eligible for the geriatric program live alone with little or no support, have a history of poor management of their conditions, take multiple medications, and have experienced multiple emergency department visits or hospitalizations.

Many of them have difficulties with activities of daily living and a history of non-adherence with disease management treatment plans. Some have catastrophic illnesses, or chronic medical issues, and need help in managing day-to-day activities.

"People in the program have a combination of issues. No patient has all of them or has just one," Westwater says.

When a patient is referred to the program, the case manager reviews his or her available medical information, then calls the patient and conducts a telephone assessment to determine if the patient is eligible for the program.

The case manager conducts an in-home assessment of the patient's medical and psychosocial needs and develops a care plan that defines the most appropriate interventions.

"The care plan identifies long-term and short-term goals and a timeline to achieve them. Patients and their caregivers are asked to incorporate personal goals into the care plan. The case manager updates and modifies the care plan as needed," Westwater says.

After the initial assessment, the case manager assigns a level of care based on the number of issues that need to be addressed, using criteria that define each level of care.

Patients on Level 1 are new referrals or those with multiple needs who need multiple visits a month. Levels 2 and 3 require less intensive management. Patients at Level 4 are being prepared for discharge from the program, and Level 5 indicates discharge.

During the first month of the program, the case manager sees the geriatric patient in the home two or three times, gradually decreasing the home visits to once a month.

"Patients who are receiving geriatric case management typically need to be followed on a long-term basis because of their complex case management issues. We have a few patients who need just a little help in getting things set up, but most are in the program for an extended time," she says.

Many of the geriatric patients need help with medication procurement or referrals to community resources. For instance, they may need a nurse aide to give them a bath or a referral to a program that can help with meals or provide medication assistance.

"We refer patients to community programs for help with everything from transportation to legal issues to weatherization for their homes. We try to find out their financial status so we can determine if they qualify for Medicaid or other assistance programs," she says.

If patients have complex medical needs and multiple comorbidities, the care managers work with Blue Medicare to set them up with electronic monitoring devices attached to their telephone that alert Blue Medicare when symptoms indicate an exacerbation in their condition.

Blue Medicare alerts the patient's Med-Link nurse, who then makes an acute home visit.

(For more information contact: Elizabeth Westwater, MedLink Community Care Manager Director, Moses Cone Health System. E-mail: