Critical Path Network

Program keeps unfunded patients out of the hospital

Program saves $500,000 a year in two years

An outpatient case management program aimed at frequent utilizers of hospital services has paid off for Seton Healthcare.

For the last two years, the initiative saved the hospital $500,000 annually in decreased utilization and identifying funding sources for the patients, according to Pat Beal, LCSW, outpatient case management supervisor for Seton Healthcare network and Seton Northwest operations manager.

The hospital developed an outpatient case management program as a result of a meeting of about 100 Seton staff from a variety of disciplines who brainstormed on how to better manage underfunded and unfunded patients.

Patients who meet the criteria for referral to the program are those who lack funding and have had three inpatient admissions or six emergency department (ED) visits during the past 12 months.

"The goal of the program is to find out why these patients keep coming into the system and to develop ways to better manage their care and keep them out of the system," Beal says.

The outpatient care management program started with one social worker and now has a staff of five FTEs. "The program has been very successful. We have plans to increase the staff by one person per year," she reports.

The program won the Innovative Program of the Year from the Society of Social Work Leadership in Healthcare in Texas.

The financial department compiles a list of patients who meet criteria for the program. Referrals also come from hospital clinicians, ED staff, local physicians, and word-of-mouth.

Case management staff review the patient records to determine what the diagnoses were, then call the patient or send him or her a letter explaining the service.

When a patient agrees to participate, a care manager does an intensive psychosocial assessment and develops goals for managing their care.

The case managers help patients find a primary care physician, obtain medication, and apply to government and community sources for health care funding. They may arrange transportation to physician visits and help them sign up for other services, such as food stamps.

In one case, the hospital purchased an insulin pump for a patient who was frequently hospitalized because her blood sugar was unmanageable.

The case manager may accompany patients on doctor visits to be a second set of ears, to help the patient express his or her concerns, and to make sure the patient follows through with the physician's recommendations. "We work to change patient behavior and to make sure that they get better care for their disease. Their quality of life improves dramatically as they become more self-sufficient and in control of their health," Beal says.

Each case manager in the outpatient case management program manages the care of 30-35 patients. "The patients flow through the service. Once we have made significant impact so they no longer utilize the emergency department, we wean them off the program and open up that spot for a new patient with high utilization," Beal says.

Another Seton program provides outpatient care management for high-risk obstetrical patients who are being seen in city clinics or in private physician offices. These patients may have gestational diabetes, may be very young or very old, have a chronic disease, or be incarcerated.

"Since we have begun case managing these patients throughout the pregnancy, we've seen dramatic improvements in outcomes for the babies and their mothers," Beal says.

The case managers make sure the patients have transportation to their doctor's appointments and call them if they miss an appointment.

The hospital also works with private physician offices to identify pregnant patients who may be at risk for complications.

The case management department has created "passports," folders with information on pregnancy and a needs assessment form to fill out. The assessment includes questions about substance use, domestic abuse, history of multiple births, lack of insurance, and whether the mom is considering putting her baby up for adoption.

If they answer "yes" to any question, they are called by the high-risk obstetrical program. The case manager may see the patient in person, or refer them to counseling or an anti-smoking program.

"We are helping physicians by providing resources to meet the psychosocial needs of the patients they're managing. It's a great service for the doctors and another way to ensure that the pregnancy has a good outcome," Beal says.

The program is open to patients with insurance or other funding as well as those who have no funding.