CMs help the chronically ill stay out of the hospital
CMs help the chronically ill stay out of the hospital
Program saves $1.4 million on just 79 patients
A community case management program for clients with complex conditions has significantly reduced emergency department (ED) visits and inpatient admissions at Poudre Valley Hospital, resulting in a savings of nearly $1.4 million for a sampling of clients in just six months for the Fort Collins, CO, health system.
The hospital provides community case management as a free service in order to help clients stay healthy in their homes and cut down on unnecessary inpatient admissions and ED visits, says Donna Poduska, MS, RN, NE-BC, NEA-BC, director of resource services for the 225-bed hospital.
"This is a community benefit completely sponsored by the hospital. In the end, it is saving the hospital money because we are implementing preventive measures that help keep the patients healthy and out of the hospital," she says.
The savings were calculated by subtracting hospital reimbursement from charges for 79 clients in the six months before they were in the program and comparing it to charges minus reimbursement for the six months after they began the program.
Before they began receiving community case management services, the 79 clients made 84 visits to the ED and experienced 73 inpatient visits. In the six months following their enrollment in the program, ED visits dropped by 48% to 44 and inpatient visits declined to 35, a 55% drop.
The hospital saved $1.4 million on 79 clients in the six months after it started the program compared to the previous six months. The total charges vs. reimbursement for the 79 clients was $1,924,000 in the six months before the program started and dropped to $537,000 after six months of community case management visits, a 72% reduction in financial loss to the hospital for emergency and inpatient services.
At the same time, the program saves clients thousands of dollars a year by helping them access community resources that can provide medical supplies, equipment, transportation, discounted housing repair services, and in-home services, says Cyndy Luzinski, MS, RN, one of the original case managers in the program.
Poudre Valley Hospital is the only hospital in a community of 140,000 and has been designated a Magnet Hospital for Nursing Excellence since 2000, been named a Solucient Top 100 Hospital, and received the Health Grades Distinguished Hospital Award for Patient Safety in multiple years.
The community case management program was among the hospital programs recognized when the health system was awarded the 2008 Malcolm Baldridge National Quality Award.
Community case management is provided by a group of advanced practice nurses and licensed clinical social workers who coordinate care for clients who are chronically ill with complex medical and psychosocial needs, and who do not qualify for other coverage for home care services.
Poudre Valley Health System began the program in 1995 when it appeared that capitated medicine was coming to the area. Capitation never materialized, but the program was a big success.
Focus on utilization issue
"We were looking at utilization issues. One of our big concerns was that clients with chronic conditions were coming back to the emergency room and being readmitted. Elderly patients with chronic illnesses were showing higher readmission rates and emergency department visits," Luzinski says.
The program began with two nurse case managers and one social worker case manager who worked with more than 180 clients. Now, the program is staffed by six case managers (five nurses and one social worker) who visit about 400 clients a year, seeing each client an average of 16 times a year.
Patients eligible for the program have complex medical and psychosocial needs and do not have reimbursement for some post-acute services, such as home health services.
They often have incomes that are too high for them to qualify for publicly funded support services but not enough to pay out-of-pocket expenses.
Clients in the program typically have limited or no family support system and have limited knowledge about how to access community services. They have a low rate of compliance with the plan of care established by their physicians.
"Most of them want to be compliant with their treatment plan, but they find it extremely difficult to do so. The cause of their lack of compliance may be that they don't understand the plan of care or it may be that they can't afford their medication. These are the people that typically fall through the gaps in the system. We are trying to fill the gaps," Poduska says.
Typical diagnoses include congestive heart failure, chronic obstructive pulmonary disorder, hypertension, and diabetes, often with multiple comorbidities.
The program originally targeted the frail elderly but was expanded to include younger clients, Luzinski says.
"The majority are elderly, but we don't have an age limit. We're seeing more younger people with complex chronic conditions," she reports.
Many of the younger chronically ill clients have cardiac issues and are referred because they have complex psychosocial issues, she adds.
The case managers have an office in the hospital but do most of their work in the field using laptops and PDAs to maintain a list of community services and other resources, Poduska says.
They meet with each other at least once a month to brainstorm about difficult clients and share information on community services.
They have an average caseload of 47 clients at a time and work with them until their identified goals are met and their conditions are stable. A few clients remain in the program indefinitely because they can't manage without support.
The case managers get referrals from physicians, the hospital, community agencies, and other families who have benefitted from the service.
The referrals also come to the inpatient case management/discharge planning/counseling office where the secretary refers the new patients to the community case managers.
The community case managers screen the referrals to eliminate potential clients who are not appropriate for the program. In 2007, the team received 302 referrals and did not open 76 of them because they were eligible for other services such as home care. Another 49 couldn't be reached or refused to participate in the program.
(For more information, contact Donna Poduska, MS, RN, NE-BC, NEA-BC, Director of Resource Services, Poudre Valley Hospital, e-mail: [email protected]; Cyndy Luzinski, MS, RN, Community Case Manager, e-mail: [email protected].)
A community case management program for clients with complex conditions has significantly reduced emergency department (ED) visits and inpatient admissions at Poudre Valley Hospital, resulting in a savings of nearly $1.4 million for a sampling of clients in just six months for the Fort Collins, CO, health system.Subscribe Now for Access
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