Medical directors are a great source of support for case management

Teamwork helped to optimize patient care

If you’re not calling on the resources of your company’s physician medical directors, you may not be maximizing your resources to optimize patient care.

"Physicians who have oversight of case management programs can play an important role in supporting and directing clinical and resource care coordination," says Sam D. Toney, MD, president and founder of Health Integrated Inc., a Tampa, FL-based company that provides integrated case management, utilization management, and disease management services for health plans, physician organizations, government entities, large self-insured employers, and other clients.

At Health Integrated, staff take a collaborative approach to case management with the nurses and physicians working as a team.

"There is a much bigger role in case management for the medical director other than just deciding whether something is an appropriate intervention," says Cheri Lattimer, BSN, the company’s executive vice president for clinical services.

Case managers should call on their medical directors for help with clinical care coordination, compliance issues, and pharmacy issues as well, she adds.

Health Integrated developed the collaborative care model as the result of interviews with the case managers. "As we talked to case managers about what is really happening as they work with their patients, they told us they need to have care conferences with physicians who can help them identify from the clinical side what might be barriers to the patient not achieving their goals," Lattimer notes.

Here are some of the ways that the Health Integrated medical directors collaborate closely with the case managers:

  • Pharmacy monitoring. If a case manager feels that a member may be getting the wrong dosage or the wrong medication, he or she can call on the medical director to look at it and contact the attending physician.
  • Dealing with a rare illness. Medical directors should be called when a member has an illness that the case manager encounters infrequently and there is not a clinical protocol for managing the care. For instance, Lyme disease is not common in most parts of the country, and the case manager might need the expertise of the medical director to manage the case.
  • Problems with the attending physician. If the patient’s physician hasn’t been available when the patient needed refills or when the patient needed an appointment, the case manager should ask the medical director to look into it and determine if the barriers can be overcome or if the patient should be referred to a new physician.
  • Experimental treatments. If the attending physician suggests a treatment option that is considered to be experimental or investigational, the medical director can review it to see if it’s appropriate for the patient.
  • Reviewing troublesome cases. For instance, if a case manager is working with a member with significant issues who is not moving appropriately through the health care continuum and isn’t reaching his or her goals, the physician can help spot obstacles to optimal care.
  • Bridging the gap between the primary care physician and case manager. Some physicians either don’t return calls or don’t work collaboratively with case managers. The medical director often can intervene and be the representative for the case manager.

For instance, one case manager brought the case of a member who wasn’t taking his medications. The member was on multiple medications, had trouble remembering when to take what pill, and didn’t have a medication organizer. The member also told the case manager that sometimes he didn’t have the energy to get out of bed to take the medicine.

"This was a red flag that the patient might be depressed. The care manager discussed the problem with the physician, and they worked together to get the member screened and treated for depression," Lattimer says.

The company holds regular and frequent case staffing meetings that include the entire team — physician, nurse case managers in both the medical and the psychiatric components of the company, utilization management nurse, and anyone else involved in the patient care.

"Our goal in every case is to identify the medical as well as the behavioral aspects of each case and determine any other options to manage the patient’s care," Toney says.

Case managers at Health Integrated have several ways of reaching the medical directors for help in managing their cases.

They can bring targeted cases to the team case-staffing meeting for discussion or flag a case for review through the company’s software platform.

"I have an open-door policy with the nurses and will meet with them in my office if that’s the most efficient way to get the job done; but in most cases, the electronic notification is effective," Toney says.

The company also has the ability for the case manager to transfer a patient directly to the medical director in acute cases.

The medical directors and case managers at Health Integrated worked together to develop clinical guidelines and tools that the case managers use every day.

"On the front end, the physician should be part of a development design team that puts into place all of the specific protocols, criteria guidelines, and assessment tools that any good case management organization must have today," Toney says.

The role of medical director is vital in the quality improvement process as well, he asserts. "They should be able to go through the interrater reliability studies and discuss the protocols and criteria used by nurses. The medical director should be available not only at the front end but during the ongoing modification of the protocols."

On a day-to-day basis, case managers should use the physician as a resource to provide individual clinical review of troublesome cases, Toney adds.

At Health Integrated, Toney reviews individual cases with the case management nurse as well as reviewing the protocols the nurse is using to monitor and coordinate the patient care.

"The second level, if appropriate and necessary, is peer-to-peer interaction between the medical director and the attending physician to discuss issues we uncovered clinically, treatment options the physician may not realize are available under the patient’s covered benefits, and to look at multiple ways of approaching various disease states," Toney says.

Under his direction, the company’s physicians are providing cross-training for the nurses on the medical management side of the company as well as the behavioral management side.

"Every case has both medical and psychological components, and the case manager does not have to be a psychiatric nurse to handle some of the behavioral aspects," Toney says.

The medical nurses are being cross-trained to handle behavioral issues and coordination of resources from the psychiatric side of care while the psychiatric nurses are receiving medical cross-training.

"Not only do the doctors work as a team in coordination of care, they are now working from the coordination of training. It’s a wonderful feeling from a nursing perspective because the physicians are getting in the trenches and working with the care managers instead of just having oversight," Lattimer reports.

Establishing the close working relationship between the physicians and case managers has been a challenge for some seasoned case managers whose longtime approach has not included physician interaction, she says.

"Over time, as we built the team approach, these nurses have provided input that they see the physician interaction as a tremendous advantage. Our case managers have told us that the help and support from a strong medical director, as well as using the clinical guidelines we have developed, have built a collaborative practice," Lattimer adds.

Involving the nurse case managers in the design of the company’s clinical protocols and care plans helped to build the team at Health Integrated, Toney notes.

As Health Integrated has developed the protocols, the company’s principals have made sure that they are user-friendly for case managers and in no way add more time to their day.

The company has been testing a new stratification tool with the case management nurses and getting their input.

"One of the things we heard over and over was that, while they want consistency and guidance, the nurses also want their lives to be made easier, not harder, by the new technology," Lattimer says.

The company takes a two-level approach to care pathways, starting with the global pathway that looks at the psychosocial and continuity-of-care aspects that are a part of every case and a specific care pathway for 45 different disease states.

"We start with the global perspective and a general care plan and come up with a variety of goals and interventions, then drill down to the specific disease state," Lattimer reports.

The integrated process guides nurse case managers who handle the care of members with comorbidities away from opening a specific care path to assessing all aspects of care.

"We look into the reasons the member may not be adhering to the treatment plan. It may be that they don’t understand their illnesses or that there are social issues or other barriers to care," says Lattimer..