In efforts to develop a robust primary care network, a large healthcare organization has embedded case managers in primary care practices.

  • The care coordination program uses a complex care team model that includes a licensed clinical social worker, a pharmacist, RN case manager, and a non-licensed professional.
  • Each day, the team looks at a risk assessment report to identify patients in need of the team’s services.
  • Outcomes have included reduced readmission rates and improved cost savings.

As the healthcare industry transitions from the pay-for-service model to a model of population health management, it’s challenging to find the right balance in care coordination. In the absence of capitated care payment arrangements, the health system has to cover the cost of teams that work to keep at-risk populations healthier.

“The need for expansion of primary care and increased healthcare access across the country is a hot topic these days,” says Tory Starr, MSN, PHN, vice president for care management at Sutter Health Valley Area in Sacramento, CA. The organization is an integrated health system with acute care hospitals, ambulatory service centers, and outpatient services.

“A lot of the fundamental elements of the Affordable Care Act [ACA] are predicated on a robust primary care network,” he adds. “What we recognized and have been trying to do is manage populations and manage risk under contractual requirements that really need a team-based approach.”

The ACA is shifting the healthcare industry to align its payment structures to promote value instead of volume to promote better care coordination and focus on health rather than illness, Starr explains.

“And Sutter is trying to do that,” he adds. “We’re making significant movement toward managing populations to promote health and integrate our delivery system.”

For example, the health system implemented a care coordination program with a complex care team (CCT) model that consists of a licensed clinical social worker (LCSW); pharmacist; a non-licensed healthcare coordinator who implements the care plan; and an RN case manager who coordinates the team. The CCT handles at-risk patients identified through various means, including a risk stratification tool, care transitions, and physician referral.

“The key to managing costs is focusing on care coordination and quality, and the costs come along,” Starr says. “If you do the right thing at the right time and right place, then you get quality outcomes, and you save money.”

This approach appears to be working: The readmission rate is less than 6% for people enrolled in the Sutter Care Coordination Program. This compares with the Medicare average rate of 18%, Starr says.

“We have significant cost savings for our managed care population, and we have about a 30% cost savings per year on patients in our program,” he adds.

The program’s limitation is that resources are limited.

“Right now, we’re at maybe 1-2% of the population, and that’s because of a capacity issue,” Starr says. “Resourcing these teams, paying for them in a non-capitated or HMO environment is challenging.”

“We are doing great work and we’re learning as we expand and take on different populations and work with different physician practices,” Starr adds. “Our challenge is to learn how to do it smarter, better, and cheaper, and that’s where the team comes in.”

The organization’s expansion of the care team model occurred due to the need for a more efficient and effective way of caring for its patient population, but the change has been a challenge, Starr says.

The following is how the program works:

Risk assessment. “Every day, we have a report that comes to each of our care centers,” Starr says. “It shows admissions, discharges, and emergency department visits for all patients within that practice, and our complex care team reviews that list.”

The team looks for whether people have been connected with skilled nursing, home health, or hospice services and whether their transitions are being managed. The team also looks for information about patients who were transitioned from acute care to their home.

Using a risk stratification tool, they identify high-risk patients and refer them to the CCT, Starr says.

“We look at everybody and make sure that if they have a Sutter physician, their care is managed,” he adds. “We also reach out to patients in the acute care setting and pull them back into the primary care setting.”

CCT embedded in primary care practices. The case management team is embedded within the primary care practice. They contact patients mostly by telephone, but also meet with patients in person when they come in to the practice for appointments, Starr says.

“We have our pharmacists doing medication reconciliation for high-risk patients that have a transition of care,” he says. “We’ve found that a pharmacist is much more effective than a physician at doing medication reconciliation.”

Case managers check to make sure the patient has everything he or she needs, including making sure the patient’s medications are reconciled, follow-up care has been provided, and that the patient is aware of his or her disease process and symptom red flags, he adds.

Track outcomes. “We have significantly decreased readmission rates, producing well-documented cost savings,” Starr says. “It’s not surprising that if people’s care is coordinated, they do better and we save money.”

“We also track advance care planning, patient-centered goals, where patients participate in their care plan because we are actively trying to get patients to be engaged with us in their care,” he adds. “We can’t do everything for every patient, so we need to help facilitate patients and their families and caregivers to build up their competencies.”

Until last year, the CCT worked primarily with Medicare and senior populations where needs were the greatest, Starr says.