Critical Path Network

CM beyond hospital walls supports chronically ill

Targets people with diabetes, asthma, HF

Recognizing that chronically ill patients benefit from care management beyond the walls of the hospital or their physician's office, Middlesex Hospital in Middletown, CT, has created The Center for Chronic Care Management, which offers four National Committee for Quality Assurance- (NCQA) accredited disease management programs to help patients manage their conditions.

"Our hospital is committed to benefiting the community. Once a person is stabilized with a chronic illness, the hospital's support doesn't end there. The goal of the program is to connect the hospital to the outside community to reduce emergency department visits for people with chronic diseases, to improve the quality of care, and clinical outcomes," says Kit McKinnon, BSN, RN, CDE, CCM, diabetes case manager and manager of diabetes care program and operations.

The hospital's Center for Chronic Care Management provides care management for people with asthma, diabetes, and chronic heart failure, along with childhood obesity and smoking cessation programs. The center, located in an office building on the hospital campus, is staffed by care managers, nurses, counselors, and dieticians. The care managers also see patients once a week in a community health center.

"Many similar programs come out of health centers. This one is unique because it's out of a community hospital. We have all these expert resources here at the hospital and are now deploying them into the community," says Veronica Mansfield, APRN, AE-C, CCM, nurse practitioner and manager of disease care and development.

The center was developed as an outgrowth of the hospital's focus on frequently occurring readmissions and how to reduce them, Mansfield says.

"Health care professionals from the community joined representatives from the hospital to develop this program. We know that at least 25% of adults in Middlesex County have a diagnosis of one or more chronic illnesses. Our goal is to improve the clinical, quality of life, and fiscal outcomes of people with a chronic illness," McKinnon says.

The hospital formed an interdisciplinary team, headed by a representative from the hospital quality department. The team included a primary care physician, a nurse, a case manager, and representatives from schools and pharmacies in the area.

The hospital purchased a data tracking system that can track patients at all points along the continuum.

The team began with an asthma program and gradually added the other diagnoses over the years.

"Right from the beginning, we were charged with being an adjunct to the primary care physician and not a substitute for care by a physician. We work with the patients and the primary care physician to make sure that patients are more educated about their chronic condition when they return to the communities they live in," Mansfield says.

Many of the patients are referred to the program from community physicians, most of whom are primary care providers, including internal medicine specialists, pediatricians, and family practice physicians.

"They believe in our services. They know that we are not a center where they send patients and never see them again," McKinnon says.

The case managers typically meet the patients when they are admitted to the hospital or have an emergency department visit.

"We are responsible for checking every day to see if there are inpatients who qualify for our program. When there are, we visit the patients in the inpatient setting. I used to do a lot of intense teaching when the patients were in the hospital, but now I do it later because they often are too sick to fully benefit from the education," Mansfield says.

The program concentrates on the most vulnerable patients, those who have problems managing their diseases.

"We work with the most complicated patients, such as those who are stratified as persistent asthmatics, who need a high dose of medication every day. Many have been hospitalized numerous times and have been intubated," she says.

Many of the patients in the program are having an inpatient admission because they can't get their medication because they became uninsured, lost their job, or for other reasons.

"We enroll them in the program, give them what they need, and educate them on how to manage their condition long term so they don't wind up back in the hospital," McKinnon says.

When they visit patients in the hospital, the case managers assess their financial status, their home situation, what they know about their medications, and what has happened with their illness in the past.

The physician and the hospitalist use information from the assessment in developing the discharge plan, McKinnon says.

"We follow the patients every day they are here. The goal is to have an appointment with them within seven days after they are discharged. They tend to bounce back to the hospital if they're not seen in a few days," she says.

When patients are in the heart failure program, the care managers see them frequently face to face as inpatients and often refer them to a home care nurse for telemonitoring.

If patients are not eligible for home care or are uninsured, the heart failure case manager works with them closely after discharge, seeing them a couple of times a week in the beginning.

The care managers facilitate getting timely physician appointments for the patients and make sure that they can fill their prescriptions.

They collaborate with community physicians to ensure continuity in care.

Some of the physicians have access to the center's electronic health record, making communication easier. There is a specialty physician group upstairs in the center's building and a family practice group across the parking lot, making it easier for patients to see their physician and visit the center on the same day.

When the patients come into the center after discharge, the case managers make sure they are taking their medication properly and start the education process now that they are feeling better. Sometimes patients bring their spouse, children, or another caregiver with them to the center to participate in the education.

"The goal is to get patients back in to see us after they have seen the primary care physician. We have at least two face-to-face visits and often many more. We also do a lot of trouble-shooting over the telephone," McKinnon says.

The hospital has a long-term relationship with the community health center and has worked over the years on quality improvement projects around chronic care, McKinnon says.

She and another RN case manager work at the community health center one day a week, providing education to patients with diabetes. Providers at the health center schedule appointments for diabetes patients on the day the care managers are present.

"The program works well because we're based here at the hospital, and if a patient who is receiving care at the community health center becomes an inpatient, we are able to see them while they are in the hospital and alert the community health center that the patient needs to be on our schedule next time we are there," McKinnon says.

One of the goals of the program is to educate people about the chronic conditions that they live with for many years.

"We are giving patients the tools to make sure they know the evidence-based standards for their disease," Mansfield says.

For instance, education for diabetics includes what A1C is, why they should check their blood sugar regularly, and how foods and medications will improve their health, she adds.

When people have acute complications of their chronic disease, the care managers work to get them stabilized, but it doesn't end there.

"We encourage the patient to continue to participate because the whole idea of community support is to provide long-term support," McKinnon says.

The care managers advocate for their patients in the community to make sure they get the follow-up care and tests they need.

For instance, one man has participated in the program since 2005, when he was hospitalized with a slight stroke and was newly diagnosed with diabetes. He came to the center with a family member and was educated on using insulin and managing his disease.

The patient owns a small business and is uninsured but doesn't qualify for state or federal assistance. Because of his diabetes, the cost of insurance is prohibitive.

The care managers worked with a primary care physician in an individual practice who agreed to treat the patient. They provide coupons for him to have his hemoglobin A1c exam twice a year and give him the support and encouragement he needs to keep his diabetes under control.

"As care coordinators, we look at ourselves as negotiators who speak for our patients to other health care providers. We were able to get him a reduced rate for his retina exam and negotiated with a dentist to get him in for an exam and to have his teeth cleaned for the first time in many years," McKinnon says.

Today, the man's hemoglobin A1c is under 7% and he is able to pay for his prescriptions for insulin and a statin.

"We get a lot of personal satisfaction from working with patients to get them active and using their medications regularly so they can stay at work and live their lives without continually being in and out of the hospital," Mansfield says.

[For more information, contact: Veronica Mansfield, APRN, AE-C, CCM, nurse practitioner and manager of disease care and development, Middlesex Hospital, e-mail:]