Sentara Medical Group’s ambulatory case management program reduced the cost of care by 17% over three years.

  • The program focuses on high-cost utilizers, most of whom had comorbid conditions.
  • The all-cause, 30-day readmission rate decreased 19% within 30 days, and patients reported improvements in their physical and emotional well-being.
  • Care managers call patients, arrange an in-person meeting, and provide follow-up telephonic support for 30-50 days.

Starting with a list of 2,500 patients who were high-cost utilizers, an ambulatory case management program effectively reduced the cost of care by 17% over three years.

The high-cost utilizers initially were adults referred by their providers, based on having catastrophic conditions related to heart disease, renal disease, diabetes, chronic obstructive pulmonary disease (COPD), and asthma.

“Our all-cause, 30-day readmission rate went down 19% in 30 days,” says Mary Morin, RN, NEA-BC, vice president, nurse executive for Sentara Medical Group in Norfolk, VA.

The ED’s treat-and-release episodes decreased by 41% from June 2010 to the end of 2013, Morin says.

Patients also reported statistically significant improvements in their sense of physical and emotional well-being.

“We found that 43% of patients had an improvement in their mental health,” Morin says. “Patients who feel better psychologically tend to take better care of themselves.”

The program now uses an 18-metric core card for advance care planning and has 14 care managers in the medical group who work with higher-acuity patients. “We no longer pick the list of patients based on a referral by the provider,” Morin notes.

“All care managers are trained in chronic disease advance care planning with two days of intensive training,” she adds. “They go into patients’ homes and discuss the advance care plan.”

In 2015, the program had 180 advance care plans, she says. “We find out what patients’ and families’ wishes are and that’s documented in the emergency medical record, so if a patient ends up in the ED [providers] can see what the advance care plan is,” Morin says.

Sentara Medical Group created the model in around 2011 with two RN care managers who provided telephonic care management for patients with congestive heart failure (CHF). There were cross-continuum teams for chronic diseases, Morin says.

“I got involved in the spring of 2011 and asked to oversee the care management piece,” Morin says. “We wanted to study the population of patients to see if RN care management could bend the cost curve, and since we have a health plan, we could get at claims data.”

With additional care managers, Morin built a new type of model with the expectation that care managers would do home visits, hospital visits, and go wherever the patient resided.

“We took care managers, including two doing telephonic work, and redesigned their model, redeploying them into a new model,” Morin says.

Each care manager received office space based on a hybrid, embedded model, Morin says.

“They could Skype with patients, and we gave all of them laptops and phones for this technology,” Morin says. “They only had to get patients to agree.”

They followed the high-cost utilizer population for three years, looking at all-cause medical admissions and readmissions, ED visits, advance care planning, and seven-day follow-up with care providers.

“We measured their perception of their physical and psychological well-being,” Morin says. “Then we monitored their utilization and we had to get providers on board, creating a bi-weekly huddle with providers.”

Care managers had to have the skill set to establish a long-term relationship with patients and caregivers. They needed to manage patients until patients no longer required intense care management, although some patients would always need that level of service, she notes.

“Care managers work closely with patients to understand them,” she says. “You can teach people about their diabetes and can teach about CHF and how to better manage their health through diet and exercise.”

Sentara Medical Group studied the results, which were very positive. The company gave the program an award for innovation and allowed it to expand with additional resources. “After three years of data, we found that we were able to decrease the cost of care by 17%, and we also learned there is seasonality to admissions and readmissions,” she says. “There also were patients who had learned behavior of using the ED as their primary care provider, and it takes a long time to change that behavior.”

The organization collects seven-day follow-up metrics because evidence suggests that quick contact with discharged patients will reduce readmissions, Morin says.

“Patients are most frequently readmitted within seven days,” she explains. “This improved by 76%.”

In 2013, the program expanded to reducing length of stay, mortality, and readmission rates for patients with CHF, sepsis, and pneumonia. “We followed up all medical discharges through the end of 2013,” Morin says. “In 2013, we added a social worker to help deal with patients who have psychosocial issues, chronic back pain, migraine pain, and gastrointestinal pain.”

The social worker works with patients when referred by care managers. Some people with chronic pain also have chronic conditions, but they need a different skill set than those with just chronic diseases, she says.

The program’s population health focus has been expanded to include a medical group of patients on anticoagulants. Registered nurses consult about warfarin protocol and provide population management. There are 17 clinics and 25 RNs who manage patients face to face and provide virtual visits regarding anticoagulant treatment, Morin says.

The program has resulted in patients having a better-than-national-average anticoagulant therapeutic range outcomes, Morin says.

“We have not had any serious safety events since implementing this model,” she says.

Starting in 2014, the team partnered with the health plan to look at Medicare Advantage populations, following all payers. “We work closely with their case managers and our care managers to manage that population, and we’ve had some great reduction of inappropriate ED utilization in that group,” Morin says.

Case managers in the program typically receive transfer forms from the hospital and ED, and they monitor and identify patients who need follow-up at discharge. There is both weekday and weekend coverage because the program quickly showed that without a 48-hour clinical assessment, patients would fall through the cracks, Morin says.

Care managers then call patients and arrange for a visit. If the patient is readmitted to the hospital, the care manager will go to the hospital to meet the person.

Follow-up appointments occur within seven days, and case managers call to verify that patients will be there. The day after the appointment, the case manager will call and continue to follow up by phone every seven days for a month. With CHF patients, the telephone follow-up continues for 50 days because data showed these patients had issues with readmissions on day 45, Morin says.

The next step would be to apply the same model to reducing readmission rates for non-Sentara physician practices, Morin says.

“We need better resources to keep people out of the hospital,” she adds.