Discharge Planning Advisor

Sutter DM, CM programs strike balance for best patient outcomes

'What are primary needs?' is operative question

The successful integration of case management and disease management is the latest step in the ongoing evolution of the Sutter Health Sacramento Sierra Region Care Management Programs, says Jan Van der Mei, RN, the region's continuum case management director.

The program began more than a decade ago with a centralized nurse/social work model that was then called geriatric care coordination, later became chronic care coordination, and is now known simply as care coordination, Van der Mei notes.

The team is composed of registered nurses located within the physician office setting and medical social workers and health care coordinators who work with patients and their families to provide a comprehensive plan of care, she explains. The team facilitates ongoing contact with both the patient and the primary care physician to make sure all issues regarding the patient's health care are addressed as quickly and completely as possible, Van der Mei adds.

The first disease-specific program was added in 2002, she says, with the management of patients with heart failure, and expanded to include those with asthma (2003) and diabetes (2005).

The Care Management Programs support two physician groups and an independent physicians association (IPA), as well as five hospitals in the region, Van der Mei notes. "They're paid for by both the hospital and the physician groups, because all benefit."

Unlike with outside companies that monitor patients for physician groups or health plans, she says, "we have been asked to provide care management for our physicians as part of the medical group structure. We have access to the chart and can make medication adjustments using guideline-based protocols."

Rather than simply telling the physician that a patient is getting worse, she says, "we can really make a difference to the patient."

The challenge in the latest phase of the Sutter Health Care Management Programs, Van der Mei continues, was to "identify a way to work together to provide disease management and care coordination and not cause total confusion."

Part of that challenge, she says, was avoiding having three different case managers overseeing the care of a patient who, for example, had heart failure and diabetes along with psychosocial problems.

"It was a gradual process, as we identified patients with heart failure who were originally referred to the program because they had issues with transportation or caregiver support," Van der Mei says. "So when we started the heart failure program, we put the patient there and then figured out if that program or care coordination manages the patient. We did it by asking, 'What are the primary needs?'"

Van der Mei describes a typical scenario:

"Say Nora, a heart failure case manager, is making her scheduled monthly call to Mrs. Jones, and Mrs. Jones tells her, 'I don't know what my weight is, because I am having trouble reading the number on the scales, and by the way, I am out of my medication and have signed up with Medicare Part D and don't know how to get my prescription filled.'

"Nora realizes she has a patient who is stable but who won't stay that way if she doesn't continue to monitor her weight and take her medications, but Nora is a heart failure case manager and has another appointment in 15 minutes."

After asking Mrs. Jones how she is doing and determining that she is not short of breath, Van der Mei continues, Nora asks the patient if it's OK if she calls the case manager who works with her physician. The case manager in the office, Linda, will then call Mrs. Jones and help her figure out what to do, Nora explains to the patient.

"After Linda calls," Van der Mei says, "she may do a home assessment or she may see Mrs. Jones when she comes in for a physician visit: Does she need an eye exam? Is the print too small?"

When Mrs. Jones' condition is stable, she adds, she will just get calls from Nora, the heart failure nurse. If the nurse identifies other problems, Van der Mei notes, or if the patient needs to be considered for hospice care, for example, Nora can make the referral or can talk to Linda about the issue, and Linda can talk to Dr. Smith.

Once Mrs. Jones is able to read the scale and handle her prescriptions, Van der Mei says, she goes back to Nora.

"So they collaborate," she says. "Who is the primary case manager is based on what is happening. If patients have comorbidities, like diabetes and heart failure, they have one of the case managers who is proficient in both diseases."

Case managers who handle more than one disease have a smaller caseload, she notes.

"The point is that the disease-specific case manager is really managing the disease, but because they have time constraints, they need support from the care coordination nurse with other issues," Van der Mei says. "You never deal just with the disease. There are always psychosocial issues."

As program staff worked to arrive at the appropriate care strategies, she says, they tried having patients with multiple needs remain in only one program, while closing them out of the other. In some instances, Van der Mei adds, the heart failure team would close out a case, turning the patient over to the care coordination team.

"If the patient got closed out from the heart failure program because so much else was going on," she notes, "then the heart failure was not managed as well, because care coordination is a more general team, not really focusing on the disease itself. So it worked out better to have the disease-specific program open and call in care coordination as needed."

One of the things Sutter Health did to enhance the quality and consistency of case management, Van der Mei says, was to identify 75 common syndromes or processes and list all the resources and interventions that might be used to address them.

"They were not necessarily diagnoses, but they could be," she explains. "We might identify all the things one would do if the patient had arthritis or was cognitively impaired, or had a fall. Intervention might be information on a support group or community resources."

Also included are processes patients should be familiar with, Van der Mei notes. "One of our goals for the program is to be sure to address advance care planning for all of our patients so they put into place an advance directive, so advance care planning is one of the categories.

"If the patient is cognitively impaired, the goal is to have a safe environment," she adds. "The interventions would include how to identify the degree of impairment and what tests the case manager should use to determine that. You would need safety measures, ways of indicating they might forget where they are.

"We've identified the potential interventions, so case managers should have everything they would consider doing for the patient in a list," Van der Mei says. "All of the identified interventions might not be indicated, but this enables a new case manager to be aware of the things they might consider for someone with the identified problems."

Sutter Care Management Programs have had success using specially trained support staff, rather than social workers or nurses, to do some of the monitoring calls, Van der Mei points out.

"When they identify problems," she adds, "the call is escalated to an RN, who does an assessment and determines what action to take. The support staff are able to do ongoing monitoring of stable patients in a fairly cost-effective way."

These employees are trained in-house, with an extensive orientation that includes scripting for patient calls and very clear parameters for when a nurse needs to be called, Van der Mei notes.

The combined programs managed more than 9,000 patients in 2006, with a total of 31 full-time equivalents (FTEs), she says. Some employees, particularly those in disease management, work in more than one program, Van der Mei adds.

Patient outcomes have been very positive, she says, and continue to improve. "Our outcomes include not only utilization measures but quality measures as well. We can clearly demonstrate that we've made a difference with our heart failure patients. There are fewer ED visits and fewer hospital visits compared to those who are not in the program, and our patients are on the appropriate drugs for their conditions."

It has always been true of patients in the care coordination program that they are healthier, have fewer visits to primary care physicians, and are able to remain in their own homes longer, Van der Mei adds. "Sometimes we have more home health visits and more durable medical equipment [DME] costs, because we make sure that patients have a cane, walker, or wheelchair."

JCAHO seal of approval

The Sutter Care Coordination Program, Sutter Heart Failure Telemanagement Program, and the Sutter Asthma Management Program received disease-specific care (DSC) certification in November 2003 and 2005 from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Van der Mei notes.

The Sutter Diabetes Management Program, which began in July 2005, will be up for certification in 2007, she adds.

"[Certification] is somewhat like accreditation, although not so complicated," Van der Mei explains. Requirements center around "how you deliver or facilitate care, that you use outcome measurements to make program improvements, and that your programs support and encourage self-management by patients."

There also are certain program management guidelines, Van der Mei says, including, for example, that the leadership roles in the program be clearly defined.

JCAHO's DSC certification is designed to evaluate disease management and chronic care services provided by health plans, disease management service companies, hospitals, and other care delivery settings, according to information on the agency's web site (www.jointcommission.org).

The evaluation and resulting certification decision is based on an assessment of:

  1. compliance with consensus-based national standards;
  2. effective use of established clinical practice guidelines to manage and optimize care;
  3. an organized approach to performance measurement and improvement activities.

Disease-specific care services that successfully demonstrate compliance in all three areas are awarded certification for a one-year period. After the first year, a one-year extension can be granted, contingent on the submission of an acceptable assessment by the organization of continued compliance with standards and performance measurement and improvement activities.