Executive Summary
Patients in Sentara Medical Group whose care was coordinated by embedded case managers showed a 17% reduction in cost of care and a 21% reduction in all-cause readmissions.
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Case managers are assigned to physician practices and schedule their time at each practice.
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They visit patients at their home or see them during an office visit and develop a care plan based on the patients’ needs.
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They follow up at regular intervals through home visits, hospital visits, group visits, and virtual visits with video chat.
After Sentara Healthcare System’s embedded case management program was redesigned, the total cost of care for patients in the program dropped by 17% over a three-year period.
All-cause readmissions were reduced by 21% for patients in the program. There was a 23% increase in advance care plans and a 77% increase in seven-day follow-up appointments. When the program started, only 21% to 30% of patients saw their physician within seven days after discharge. Now, the rate is typically in the high 80% range, and has been as high as 98%, according to Mary Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group, a division of Sentara Healthcare System, which operates throughout Virginia and northeastern North Carolina.
Before Morin joined the medical group in 2011, the health system had two embedded case managers in two medical practices and two telephonic case managers who worked in the corporate office. The program targeted heart failure patients in two primary care practices and those who were indigent or self-pay and who had received care at two hospitals. "The nurses were spending 75% of their time functioning as an office nurse bringing in patients or acting as a personal nurse to a physician," Morin said.
As part of the redesign, Morin and her team developed all new job descriptions and set out expectations for the case managers. The program uses only bachelor’s-prepared nurses who have at least three years of acute care or ambulatory nursing care experience. If they are not already certified, they must sit for certification within a year of eligibility.
The redesign of the program removed the case managers from the physician offices and corporate offices and expanded the focus to 11 practices. Now patients from all payers, including Medicare and Sentara Health Plan, are eligible for the program. The program has expanded to 38 primary care practices.
The case managers are assigned to physician practices and schedule their time at each practice. They have an office in each practice to which they are assigned, and are part of the care team in each practice. They are equipped with smartphones and laptops.
The case managers were told their jobs would change when the program was revamped, but they didn’t realize all that was involved, Morin says.
"I had 100% turnover within a year and 75% turnover in six months. In retrospect, I should have made them reapply for the job," she says.
The case managers received education on motivational interviewing, engaging patients and family members, understanding and managing chronic disease, pharmacology, family dynamics, and community resources.
Sentara developed a computer platform allowing the case managers to keep their schedule up to date and track data on their patients.
Morin and her team focused on patients who were identified as high-cost, high-utilizer patients, except for patients with cancer, trauma, and other catastrophic illnesses. The remaining patients had renal failure, heart failure, diabetes, chronic obstructive pulmonary disease, chronic pain, and behavioral health issues. The majority of patients in the program range in age from the 30s to the early 60s.
About 2,400 patients who met all the criteria were patients at the 11 participating practices. The team asked the physicians to identify those who would most benefit from interventions. The goal is for the case managers to have an average caseload of around 150 patients, she says.
When the program began, Sentara sent out letters to the targeted patients and the case managers contacted them by telephone and saw them in the hospital whenever possible, Morin says.
"We got 100% engagement from patients we visited in the hospital and only 80% engagement when we sent letters. People are eager to participate when they’re in the hospital," she says.
Once the patients agree to join the program, the case manager makes a visit to the home or sees the patient during an office visit to make an initial assessment, facilitate the patient in developing an advance care plan, and develop a care plan based on any needs the patient might have. The case managers set up a routine touch point with patients. They call or see some weekly, others quarterly, and some every day, Morin says.
The case managers are able to see through the electronic medical record the list of patients coming into each practice and, based on this, they develop a schedule, she says. Their goal is to see patients face to face when they have a physician visit.
Case managers are alerted when patients are admitted to the hospital and visit them whenever possible.
The case managers call the frequent emergency department users to check on them. They may make home visits if they feel the patient needs extra support. The care managers follow all medical patients who are discharged from the hospital for at least 30 days as part of the medical group’s intense transition process to reduce unnecessary emergency department visits and hospital readmissions. Some of these patients will become long-term care management patients if they have complex diseases or conditions, Morin says.
"The case managers engage the patients and manage their care through home visits, hospital visits, group visits, and virtual visits with Skype. Patients see the case managers as an extension of their physician, and someone they can call on when they have questions and concerns. Seeing patients in the hospital and going into the home to meet patients on their own turf has paid off greatly," she says.
The physicians in the program have worked with Morin and her team to create an insulin protocol and a furosemide protocol that the nurses can implement, helping the patient avoid an emergency department visit. "The case managers have developed a relationship with the patients who call them when they have symptoms rather than going to the emergency department," she says.
When the program started, the case managers and physicians had a 10-minute huddle every two weeks. "Now the case managers and physicians talk all the time. The physicians see the case managers as someone who is working with them and watching out for them. They’ve realized how many times they aren’t getting interrupted," she says.
One case manager convinced a skeptical physician of the value of the program by working with a patient who was going to the emergency department once a week. That was two and a half years ago and the patient hasn’t been back to the emergency department, Morin says.
