Critical Path Network

Coordinating care throughout continuum keeps patients out of hospital, emergency department

Program is funded by hospitals, medical groups

By providing care coordination throughout the continuum for patients with multiple chronic conditions, the Sacramento Sierra Region of Sutter Health has significantly decreased emergency department visits and hospitalizations.

Sutter's care coordination program combines chronic care and disease management, according to Jan Van der Mei, RN, MS, ACM, regional director of continuum case management for the Sacramento, CA-based region. Sacramento Sierra Region includes five hospitals, two medical groups, and an IPA.

In 2008, patients in the care coordination program had 32% fewer ED visits and 21.1% fewer admissions than patients who met the program criteria but were not in the program. Patients in the heart failure disease management program had 49.8% fewer ED visits and 51.9% fewer hospitalizations than patients with the same diagnosis who were not in the program.

In the first six months of the transition-of-care program for Medicare Advantage patients being discharged without home health, the readmission rate for those patients was 5% compared to an average of 19.6% of Medicare beneficiaries, according to a study in the April 2, 2009, New England Journal of Medicine.

Patients eligible for Sutter's program are struggling with chronic care management. They have experienced multiple hospital admissions and/or ED visits, have a history of medication noncompliance, have a lack of community or social support, have been discharged from an acute or skilled nursing setting, or are at risk for high utilization of medical services. Some are in the program at the request of their caregivers. Children with severe, chronic asthma also are eligible.

Funded by hospitals, medical groups

The continuum case management program is funded by the hospitals and medical groups in the Sutter region.

The care coordination program was implemented in 1994 to target the frail elderly in response to the health system's move into a full-risk capitated program for seniors. The disease management components were added between 2001 and 2005. The transition-of-care program to prevent readmissions was begun in 2008.

The nurses and social workers in the care coordination program work out of the patient care centers. All internal medicine and family practice doctors are assigned a case manager.

Social workers and nurse case managers work as a team to coordinate whatever care the patient needs, referring patients to their counterparts if the other discipline has more expertise.

For instance, the nurses typically take patients who are medically complex, and the social workers have primary responsibility for patients with psychosocial needs.

"Before we moved our staff into the physician offices and explained the role the case managers play, the physicians had the impressions that case managers were gatekeepers. We had to give them concrete examples and stories of how the case managers can help them," Van der Mei says.

The care coordination program gets about 200 referrals a month, with the vast majority coming from physicians.

Heart failure patients were the first disease-specific program. Originally, the health system outsourced the program to a vendor that would send the physicians fax alerts. The physicians didn't find that to be an effective process.

Heart failure protocols developed

Working with the medical staff committee, the department developed heart failure protocols that the nurses use to make medication adjustments and order lab work.

"The protocols are detailed with guidelines on how to treat patients in a particular situation. The nurses keep the physicians aware of what is happening with the patients and call the physicians in if the patients don't respond to treatment," Van der Mei adds.

For instance, if a patient has gained a certain amount of weight, the nurse follows the protocol to increase the furosemide, then monitors the patient closely, calling daily. If the patient doesn't respond well to treatment, the nurse refers the patient to the physician.

Disease management specialists, who are trained paraprofessionals, make scheduled calls to stable heart failure patients every two weeks or once a month, based on the patient's risk level. They follow a script to ask about weight gain, shortness of breath, and collect other clinical information.

They conduct periodic educational sessions with the patients, such as teaching them how to read labels for sodium content, or cautioning them against eating a lot of ham or other salty foods during the holiday season.

"Heart failure patients can manage very well if they are followed closely. If they're not being followed, when they become symptomatic, they are likely to go to the emergency department and get admitted," Van der Mei says.

The heart failure nurse managers call all patients right after they are discharged from the hospital.

"The first two weeks following a hospitalization are crucial in helping heart failure patients stabilize and remain out of the hospital," Van der Mei reports.

The nurses call the patients as often as every day if needed until their condition becomes stable.

The disease management specialists call the stabilized patients regularly to monitor them in case their condition changes. When patients report weight gain or increasing symptoms, the disease management specialists refer them to the RNs.

"We do a lot of education around teaching patients when to call us," Van der Mei says.

The program targets other vulnerable populations, including patients who have medically or socially complex needs.

The health system has developed a program for managing patients on blood thinners that uses protocols and works in the same way as the heart failure program.

The team coordinates care for diabetes and asthma patients in a different way, concentrating on educating the patient to self-manage his or her disease, rather than managing the patients.

"In the diabetes program, we facilitate the doctor's orders. We make sure the patients get their recommended tests and procedures, talk to them about barriers to adherence, and educate them about their disease," Van der Mei adds.

The nurses educate the patients with diabetes and asthma and follow up when the labs are abnormal. The disease management specialists make some monitoring calls to appropriate patients but spend most of their time calling patients to remind them that lab tests or procedures are due.

"The program helps to keep patients out of the hospital. In addition, the management of patients with diabetes and asthma helps improve patient care and quality along with helping the physicians improve their pay-for-performance data," Van der Mei says.

The care coordinators and disease management nurses work together to ensure that patients get everything they need.

For instance, the disease management nurse may call heart failure patients to check on their condition and find out that they can't report their weight because they can't read the print on the scale or haven't gotten their medication filled.

The nurse calls the patient's doctor's case manager who can help the patient get medication assistance or find a scale with big numbers.

The case managers in the physician offices also help keep inappropriate patients out of the ED because they can place them in a skilled nursing facility, rather than sending them to the hospital for placement.

Another component of the program is talking to patients about end-of-life care, palliative care, and advance directives.

"The whole goal is for the case managers to have these conversations early on so people can start thinking about the issue. That way, it doesn't come as a surprise when someone brings up hospice or palliative care. We can project how a chronic disease is likely to progress and help the patient understand and prepare for it," Van der Mei says.

The continuum case managers work closely with Sutter's hospital-based case managers to coordinate care for patients who are hospitalized.

"When patients in our program are admitted, the physician office case manager is alerted and can call the hospital case manager to let her know what it going on. The hospital case managers can call us if they have questions or difficulties with the patients," Van der Mei says.

When patients from the physician office are headed to the ED, that case manager calls the ED case managers and fills them in on the patients' condition and reason for coming to the hospital.

Model developed for those without home health

The health system has developed a transition-of-care model to follow Medicare Managed Care patients who are being discharged without home health. The program is staffed by health care coordinators who introduce the program to the patients in the hospital.

They make the initial call after discharge and then transfer the case to the patients' office case managers who call the patients on Day 2 after discharge. The office case managers call again on Day 7 and follow up regularly for the next six weeks. They conduct medication reconciliation, ensure the patients make and go to their follow-up appointments, and talk to the patients to determine if there are signs and symptoms that indicate their condition is deteriorating.

"It's amazing how many times the case managers find discrepancies in the medication prescribed and how the patient is taking it. The hospital does medication reconciliation, but that communication is only as good as what the patients remember they are taking at home," Van der Mei says.

The program aims to help patients avoid readmissions.

"Eventually, we would like to do this for all Medicare patients, but at this time, we don't have the resources," Van der Mei says.

The Sutter care coordination program was asked to submit the program to the Agency for Healthcare Research and Quality's Health Care Innovations Exchange, a program designed to accelerate the development and adoption of innovations in health care delivery. The regional case management department won the initial American Case Management Association/Joint Commission Franklin Award of Distinction in 2003.

"Our program was found to be distinctive because of the innovative way the department spans the continuum of care," Van der Mei says.

(For more information, contact Jan Van der Mei, RN, MS, ACM, regional director of continuum case management for Sutter Health's Sacramento-Sierra Region, e-mail: