Care coordination program addresses wide range of issues that result in repeated emergency department and hospital visits, including issues related to social determinants of care.

  • Program results in 25% decrease of inpatient utilization and 33% decrease in emergency department use.
  • It uses a robust algorithm to identify patients’ risk status.
  • Care managers, embedded in primary care offices, provide follow-up phone calls to patients, giving needed information and making certain they have follow-up appointments scheduled.

Embedded care managers in primary care offices, telephonic care managers, and a population health approach have helped a major health system in its transition from a fee-for-service model to a value-based care model.

Nine years after deciding to embrace a total health model that uses a holistic approach to caring for patients, the Greenville Health System (GHS) in South Carolina has stacked up success stories, says Jennifer Z. Snow, MBA, director of accountable communities at GHS.

“In 2007, GHS committed to becoming a total health organization where we care for the whole patient, taking a holistic approach,” Snow explains. “In 2009, we started our first attempt at managing a patient population, with a grant funded by The Duke Endowment, in our internal medicine clinic.”

The program began with an initial focus on identifying high-risk patients by disease states. “Within that first year of the grant, we decided we needed to adjust our approach and changed the model,” Snow says. “We started looking at emergency room utilization and hospital admissions.”

The grant-funded pilot program had a care management team that included a nurse care manager, a social worker, and added primary care access with a nurse practitioner. The team worked with patients at the internal medicine clinic, she says.

What GHS and care managers discovered is that patients’ health conditions only accounted for about 20% of healthcare costs, Snow says.

“It is well known in the industry that 80% are more reliant on social determinants of care, rather than health conditions,” she says. “We took that model and nurse care manager approach to include a focus on social determinants to our ER department and were also successful managing care in our internal medicine clinic.”

The program added care managers to the employee health plan, Snow says.

“They looked at the at-risk patients within the physician practices and targeted care interventions based on the patient’s condition and risk level,” Snow adds.

“We have seen reductions in emergency department utilization, in inpatient admissions and readmissions, and we’ve also seen clinical outcome improvements in terms of lowering cholesterol levels and hemoglobin A1C,” says Nancy Markle, RN, vice president of care transformation, Care Coordination Institute at GHS. The care management program focuses on care coordination across the continuum of care, and the team includes registered nurses, social workers, health coaches, and community health workers.

Outcomes from care coordination among the health system’s Medicaid population include the following:

  • 25% decrease of inpatient utilization,
  • 33% decrease in emergency department use,
  • 300% increase in wellness and prevention visits, and
  • 20% decrease in 30-day, all-cause readmissions.

After the health system expanded the care management program to its 15,000-employee population — which largely is self-insured by the health system — similarly positive results ensued, including a reduction in hemoglobin A1c from 9.02 to 8.56 within one year for patients with diabetes.

The care management program continued to grow. It expanded to more populations, including an accountable care organization (ACO), which has a contract with the Centers for Medicare & Medicaid Services (CMS) for approximately 56,000 Medicare Shared Savings Program beneficiaries. It’s also expanded to a population of uninsured, high-risk patients, and it has been offered as a service to more than 100 employers for their high-risk employees. Now there are more than 40 employees in the health system’s ambulatory care management program, Snow says.

The following is how the program works:

A robust algorithm identifies patients’ risk status. Care management is a costly resource, so it’s used with patients at the greatest risk of having poor medical management, high costs, and overutilization of hospital resources. The Care Coordination Institute also looks at data from ICD-10/CPT 4 codes to identify those who would most benefit from care management, Markle says.

“We looked at triggers to identify patients for care management,” she says. “We break these up between inpatient and outpatient and chronic diseases with the potential of down-the-road complications, including diabetes, asthma, hypertension, heart disease, depression, and other indications that indicate poor self-management.”

These additional triggers include frequent emergency department visits, frequent hospital admissions and readmissions, psychosocial barriers to care, and lack of caregiver support, Markle says.

“That’s a broad overview, and the risk stratification analytics and algorithm take a much deeper dive into the data,” Markle says.

A transitional care component targets those at high risk. Patients with acute care admissions and a high risk for readmission, poor outcomes, and increased utilization receive a 30- to 90-day intensive course of care management.

“In addition to our ambulatory care management approach, we have established our patient-centered medical neighborhoods model,” Snow says. “We have identified at-risk neighborhoods and deployed the resources in the communities where our patients need them the most.”

Some high-risk patients need home visits, which is a program GHS provides to the most vulnerable neighborhoods in its county.

“We have a community paramedic and social worker who go to people’s homes and help them set up pill reminders, arrange transportation, talk to the patient’s family about caregiver support, and do anything else they can to address the social determinants of health,” Snow says.

Care management includes a focus on social-behavioral obstacles. For example, one person targeted with case management services had visited the emergency department nearly 150 times, including almost 40 in one year, Snow says.

Once the patient’s case was closely assessed, the care team discovered that the visits were unnecessary, almost always the result of the patient needing non-emergency medical care but not having transportation to get to a doctor, she explains.

“All this patient needed was a primary care provider and access to a gastrointestinal doctor,” Snow says. “We arranged for transportation and got the patient into a primary care home, and now the patient sees that provider and doesn’t come to the ER.”

Another patient they assisted had a change in blood pressure medications that the patient was not taking correctly, Snow recalls.

“It was making the patient sick, so we sent someone out to the home to explain the change in medication and how to set up pill reminders,” she says.

Other examples include a asthma patient who lives with a smoker. “So we went into the patient’s home and asked the roommate to smoke outside, and help change air filters,” Snow says.

“It can be any of these social determinants of health,” she says. “We look at the patient as a whole.”

The healthcare delivery system is difficult to navigate for everyone, but especially daunting for people who lack access and resources, which is why care management can make a big difference in outcomes.

“We’re bridging that gap in the communities where patients who need it the most live,” Snow says. “We need to be innovative with our care management design.”

Care managers provide support to physicians and office staff. “Our philosophy is that we position the care managers as a support to the physicians and their office staff,” Markle says. “We take on a lot of the interventions between office visits so physicians can focus on the care at the point of service.”

Care managers provide follow-up phone calls to patients, making certain they have follow-up appointments scheduled. They provide patient education and coordinate with clinical pharmacists for medication reconciliation, she says.

“Our care managers do a lot of coordination and support physician care,” Markle says. “The staffing model consists of both embedded care managers in practices with large volumes of high-risk patients, as well as telephonic care managers that can cover several practices with lower volumes.”

The embedded case managers log into computer systems that are linked with physician offices’ electronic medical records so doctors can access any care plans case managers created with patients, she notes.

Care managers who manage via phone provide the following care management services:

  • They call and/or visit patients to assess risk status.
  • They call patients who have been discharged from the hospital within 24 hours of discharge and schedule a follow-up appointment within 48-72 hours after discharge.
  • They provide telephone interventions tailored to patients’ risk levels, including calling the highest-risk patients more frequently and focusing more on health and wellness with the lower-risk patients, Markle says.