Since Lehigh Valley Health Network started its Community Care Team initiative in 2012, at-risk patients who received interventions from an interdisciplinary team of clinicians reduced hospital admissions by 49% and emergency department visits by 25%.

The Allentown, PA-based health system’s care management program deploys teams of four clinicians to primary care practices to coordinate care for the top 5% of high-utilizing, high-cost patients at each practice, according to Kay Werhun, DNP, MBA, RN, director of population health. Each team includes a nurse care manager, a social worker, a behavioral health practitioner, and a pharmacist, she adds. “Our goal is to add an additional level of care management that will concentrate on the next 25% of patients whose conditions put them at risk and intervene to keep them from becoming high risk,” she adds.

The program includes physician practices owned by the health system as well as independent practices. Currently, the program is in place in 24 practices in five counties.

The program started with six practices that had been identified as being forward thinkers that were in the process of seeking medical home certification. The health system added new practices between 2013 and 2014, based on the number of high-risk patients and/or the number of Medicare patients. Lehigh Valley Health Network was recently approved to be a Medicare Shared Savings Program participant, according to Werhun.

Patients eligible for the program have five or more chronic conditions, three or more abnormal clinical indicators, are taking seven or more medications, and/or two or more emergency department visits or inpatient admissions within the last 180 days, Werhun says. “The health system utilizes sophisticated data analytics tools to identify at-risk patients and those with a high probability of readmission,” she adds.

The program is hospital-based, but the team members spend most of their time in the field, Werhun says. The nurse care managers typically work in two to three practices and the social workers three to four practices. The behavioral health practitioners work in three practices and the pharmacists cover 10 practices. In larger practices with a high volume of patients, the team may be on-site up to four or five days a week. The clinicians rotate through the smaller practices.

The team provides a combination of telephonic and face-to-face interventions. The nurse care managers contact patients who have been identified as being at high risk within two business days of any hospital admission, conduct a comprehensive review of the patient’s discharge instructions, complete a medication reconciliation, educate the patients when needed, and make sure they have filled their prescriptions and have a follow-up appointment.

If the care managers identify barriers to adherence with the patient’s treatment plan, whether they are financial, social, or emotional, they refer the patient to the appropriate team member.

The nurse care managers also reach out to patients who have not been hospitalized but are on the high-risk registry and refer appropriate patients to other team members for interventions.

“We try to get to the reason and the barriers that patients face that may limit their ability to adhere to their care plan. Frequently, there is a socioeconomic barrier,” she says. In those cases, the care manager will get a social worker involved to help patients with applications for discounted and free medication, set up housing assistance, arrange for transportation, and help them access community organizations, she says.

There is a national shortage of behavioral health therapists, which means patients frequently have to wait for extended periods of time for an appointment, Werhun says. The Community Care Team’s behavioral health specialists provide six to eight free counseling sessions to patients who need them, bridging the patient to a long-term provider.

“All of these services are free to the patient and free to the practice. Our goal is to fill the gaps in care and reduce unnecessary utilization, whether it’s a hospital admission or emergency department usage. We work to help the patient understand their disease process and set goals to manage on their own,” she says.

The frequency with which the care managers contact the patients depends on patient needs. “Some are able to manage fairly well and just need an encouraging telephone call once a month. Others need a call every day to support them in following their treatment plan,” Werhun says.

The case managers develop a close relationship with the patients, who often share information they wouldn’t tell their physician, Werhun says. “Ascertaining social and economic determinants in a 15-minute appointment is very difficult. Patients frequently leave their appointments without mentioning that they have do not have heat, water, and food at home,” she says.

The Community Care team care managers and the inpatient hospital case managers are working to increase collaboration and share information by telephone and through the electronic medical records, Werhun says. “The inpatient case manager may know something about a patient that the Community Care Team care manager does not. By sharing information, everyone knows as much about the patient as possible and can provide better care and avoid duplicating tests or services that the patient received in the other setting,” she says.