CM and UM departments are separate
A program in which case managers coordinate the care of members with complex medical conditions and those who are at high risk for chronic diseases has paid off for Care Choices HMO of Farmington Hills, MI.
Evaluation of the case management program is based on member satisfaction, functional improvement, and resource utilization.
"Our utilization measures such as bed days per thousand, admissions per thousand, and length of stay are at a very good rate. Case management is an integral part of the disease management programs and as such is included in the return-on-investment analyses," reports Saraja Samuels, RN manager of medical management.
The health plan made the decision several years ago to have separate departments for utilization management and case management.
"When we started the program, the case managers did utilization review and case management. Now, we have certified case managers who strictly do case management," Samuels says.
When case managers also handled utilization management, that was their priority, and case management was always on the back burner, Samuels says.
"This way, the case managers have no distractions. They can concentrate and spend time on managing the patient care. In the case management area, people are very fulfilled, very happy, and helping the members," she adds.
Care Choices HMO Case Management Program deals with members who are at high risk for chronic diseases; those who have an illness that could lead to a high-risk condition; and members who need increased use of health services.
The Care Choices disease management team handles routine disease management.
If a member with a chronic disease is hospitalized or visits the emergency department, the case managers handle his or her care.
For instance, the disease management team would manage members who have their asthma under control. If they end up in the emergency department, the case manager would take over the care.
"The members whose care we manage are those who are at risk," says Karen Bray, RN CCM, team leader for case management department.
The HMO Case Management Program also provides care for patients with increased use of health care services, such as those who are being followed by several specialists, have multiple durable medical equipment needs, or need extensive wound care.
Patients who are waiting for a transplant, those with end-stage renal disease and spinal cord injuries, and premature infants also are referred to case management.
The severity of a member’s disease determines whether he or she gets into case management. For instance, when a member is diagnosed with hypertension, the disease managers get the information from pharmacy data and send the member information about blood pressure.
"If a member has high blood pressure and is going to work every day and keeps it under control, they don’t need case management. If they’re going to the emergency room a couple of times a month or end up in the hospital, it means they’re not managing the disease, and that’s where case management come in," Samuels says.
The Care Choices HMO case managers work with the member and the primary care physician to assess the member’s health care needs and develop a customized plan.
They coordinate services, monitor the member’s compliance with the plan, and evaluate treatment plans on an ongoing basis.
The goal is to help the members manage whatever disease or condition they have, Samuels adds. "Some are not going to be 100%; but if they can live with the disease they have, go back to work, and live a normal life, that’s our goal," she says.
The staff in the HMO Case Management Program are experienced case managers with medical/surgical backgrounds and different specialties.
"We all work with all members; but if there is a case that comes up that needs someone with a more specialized background, we have case managers who can handle it," Bray says.
For instance, she has experience with transplant patients and handles all of the transplants.
When a patient is referred to case management, the case manager collects patient history, pharmacy data, and other information, then calls the primary care physician to get his or her approval for the patient’s enrollment.
If the member has an acute need, the case manager calls him or her. If the need isn’t acute, she sends an introductory letter and follows up with a telephone call.
"I have found from my past experience that people are more apt to speak to you if they know you’re going to call and know why you’re calling," Bray says.
The letter explains the benefits of case management and asks the member to call at his or her convenience. If the members don’t call within a couple of weeks, the case managers call them.
An acute patient who would warrant an immediate phone call might be someone referred by utilization review who has new-onset diabetes and has been hospitalized.
"Hospital stays are much shorter these days, and teaching is more intense and quicker," Bray says. "Diabetes is an overwhelming diagnosis, and it’s hard for someone to understand quickly what is happening."
With the acute patients, case managers try to call on the day of discharge, making sure the patient has whatever durable medical equipment he or she needs and is clear on when to make a follow-up visit to their physician.
"We let them know the benefits of case management and our educational resources. If they seem to be overloaded, I’ll leave a number and ask them to call in a few days," Bray says.
Patients who receive a letter before a case manager calls are likely to be people with a chronic disease who have been to the emergency department or whose pharmacy data indicated they haven’t been complying with their medication.
"We try to find out their knowledge base regarding their condition and go from there. If they seem to be knowledgeable, it might be a compliance problem that means a follow-up with the physician or change in medication," Bray says.
If the members’ problem is compliance with their treatment regimen, the case managers educate them and tell them the benefits they have with the health plan, Samuels notes.
"Many people don’t know that they can have two nutritional consults a year. Others don’t know that diabetics should have specific lab tests or have a dilated retinal eye exam each year. They think that if they go to the physician every year, they’re doing everything they should," she adds.
The case managers educate them on what they should do to keep their condition under control and let them know what benefits they have at Care Choices that can help them manage their diseases themselves, such as weight management and smoking cessation programs, Samuels says.
If members’ benefits have run out or they have needs that aren’t covered by the health plan, the case managers will help them find community resources. For instance, there are community organizations that will provide wheelchair ramps and others that will help pay for medication that isn’t covered.
"We perform telephonic case management; but if we feel that a patient needs an assessment of the home environment, we make arrangements for a visiting nurse or home care nurse to do the assessment," Bray says.
The case managers follow the members as long as they need it. Patients whose conditions are fairly stable but still need some oversight are put on monitor status.
For instance, the case managers follow patients with end-stage renal disease and monitor them closely after they start dialysis. If they are stable, they are put on case management monitoring status and are not in active management again until they start having problems or need a kidney transplant.
Transplant patients are handled from the time the health plan gets a request for an evaluation visit until a year or two after the transplant.
"It’s really individualized. I had one case that was in case management for two weeks and others who are awaiting a transplant or who have multiple comorbidities that require case management intervention for two years or more," Bray says.
The case managers close the books on members when the members have a good knowledge base about their condition, are stable, are in compliance with their treatment regime, and follow up with their primary care physician at least once a year.
"If we are comfortable and they are comfortable, we close the case," Bray reports.
The case managers are assigned to patients being treated by particular provider panels.
"It’s helping; because when we work with the provider offices, the nurses and physicians get to know the case managers," Samuels says.
Each of the four case managers handles between 120 and 200 patients at any given time. Many of them are on monitor status, and the case manager may just touch base every month or two, Bray reports.
Others require more intense interventions. "I have had several members I called daily or every other day for two or three weeks on end. These are patients with multiple comorbidities or those who have had a lengthy inpatient admission. Once they get home, I want to make sure they have everything they need so they don’t end up in the hospital," she says.