CMs follow up by phone after discharge

Transition from hospital to home eased

At Independence Blue Cross in Philadelphia, case managers work closely by telephone with Medicare Advantage members with chronic conditions that put them at risk for rehospitalization, which helps them transition from the hospital to the community and ensures that their needs are met after discharge.

The program, which began in April 2011, is a redesign of the insurer's successful Transitional Case Management Program that provided face-to-face visits to eligible members while they were in the hospital and telephone follow-up after discharge.

"As many of the hospitals in our area began to focus on their own transition-in-care programs, we felt we could better serve our members if we converted to a telephonic model," says Diana Lehman, RN, BSN, CHIE, director of case management for Independence Blue Cross.

Members eligible for the program are those with conditions and/or comorbidities that put them at risk for readmissions. These conditions/comorbidities include congestive heart failure, pneumonia, pulmonary diseases, cardiac issues, and renal problems. Members who could benefit from the transitional care program are identified based on their condition as well as being referred when the health plan's utilization review staff determines that a member has complex needs.

Case managers call the eligible patients while they are in the hospital to remind them to review the discharge summary with hospital staff and stress the importance of filling their prescriptions and making a timely follow-up appointment with their primary care physician. They educate the members about their chronic condition and symptoms that indicate they should call their physician.

After discharge, case managers follow the patients an average of 90 to 120 days, depending on the individual's needs. Shortly after discharge, the case manager conducts an in-depth telephone assessment of potential needs and barriers to following the treatment plan. The assessment looks at the member's cognitive and language abilities, functional limitations, the extent to which they are taking medications as prescribed, transportation needs, and end-of-life planning.

The case manager and the member review the discharge plan and medication regimen and work together to develop a plan that will help the member achieve optimal level of wellness. If members are taking duplicate medications or are confused about them, the case managers urge them to contact their physician for clarification. They help the members schedule doctor visits and often work with caregivers to determine members' needs.

"The case managers look holistically at what is going on with the members and, in addition to taking care of discharge issues, link the members with community resources and collaborate with our pharmacy and behavioral health divisions to make sure they get the services they need," Lehman says. For example, the case managers collaborate with the pharmacists in finding less expensive alternatives if patients report that they can't afford their medication. Armed with information from the pharmacist, the case manager will facilitate a conversation with the physician and ask if a less costly alternative medication would be effective.

The Medicare case management team and some of the behavioral health team work in the same office, which enables them to co-manage members with depression, anxiety, and other mental health issues. When members need community resources, such as help with transportation to physician visits, the case managers can call on a social worker for assistance. The social work team at Independence Blue Cross works closely with the Philadelphia Corporation for Aging to identify services for members and has a representative on the organization's advisory committee.

If the case manager has any concerns about the member's condition or understanding of the treatment regimen, he or she can contact the home health nurse for more information. For example, the treatment plan for patients with congestive heart failure calls for patients to eat a low-salt diet and to weigh themselves daily. If the Independence Blue Cross case manager has difficulty determining information about the patient's weight gain or diet by telephone, he or she would call the home health nurse and ask for more information. Depending on the situation, the case manager might relay the information to the patient's doctor.

In situations in which home health has not been ordered, if the case manager thinks the patient might benefit from home health visits, he or she will call the patient's physician, explain what is happening and ask for an order.