EXECUTIVE SUMMARY

A case management program that targets frail seniors with a combined case management and technological tool solution produced significant cost savings in a pilot study.

  • The program included technology that monitored frail seniors’ movements within their homes.
  • After establishing a baseline pattern, the technology could flag outlying activities, and case managers use that data to call and check on the patient.
  • The goal was to reduce hospitalizations and ED visits.

A case management program that helps frail seniors retain independence and stay home saved $687 per member per month in its pilot study.

The initiative is part of Fallon Health’s NaviCare program, says Lynn Patterson, RN, CCM, senior director of NaviCare Clinical of Fallon Health in Worcester, MA.

Started in 2010, NaviCare is for seniors ages 65 and older who are eligible for benefits under MassHealth Standards, the Massachusetts Medicaid program. They also can be enrolled in Medicare, but that’s not a requirement, Patterson says.

About two-thirds of people enrolled in NaviCare live in the community with functional deficits, such as needing assistance with their activities of daily living, says Gerald Gleich, MD, medical director at Fallon Health’s NaviCare Program.

Technology Detects Behavioral Patterns

The pilot study looked at health outcomes of seniors who lived alone and whose case management was supplemented by the use of Healthsense’s passive, remote technology in patients’ homes, says Ellen Briggs, RN, CCM, NaviCare clinical manager.

“This technology monitors their patterns of movement within the home,” Briggs explains. “If someone goes to the toilet tank, the device will monitor how often the person is flushing the toilet.”

Patients offered the technology were among the most frail. They would have been eligible for nursing home care, but they could choose the technology as a way to help them stay at home, Briggs says.

When the senior opens a kitchen cabinet where the medications are located, opens the refrigerator, gets in or out of bed, or sits in a chair, all of this activity is collected and timed. For the first two weeks, the technology monitors activity and establishes a baseline pattern, Briggs says.

Once this pattern is identified, the system continues to monitor the person’s movement, looking for a deviation from the baseline pattern. If there is a change, the technology automatically notifies the NaviCare team.

“They let our staff know through our electronic health record that the senior spent an increased amount of time in bed or on the toilet,” Briggs says. “This is an opportunity to get the person to see a physician; if there is an episode of increased toilet use, then there might be a urinary tract infection, and we’ll get a specimen to the lab.”

The technology gives NaviCare staff a chance to intervene. Once notified, someone will call the plan member and ask a few questions to see whether the technology produced a false positive or identified a real problem, Briggs says.

“By monitoring their movement, we can identify problems before they know about them,” Gleich says. “It’s a useful tool when it’s used as a companion to what case managers ordinarily do.”

The technological solution was continued after the pilot project ended, and all plan members who live alone and are qualified for skilled nursing facility (SNF) assistance are considered eligible for it, Briggs notes.

“It’s one tool among many, and the reason we’re continuing it is because the pilot was effective, and we’ll look at it year to year to see if we need to modify it,” Gleich says.

Case managers can call at-risk seniors on a regular basis, but they might miss early clues of a problem. Using the technology to identify problems through pattern changes helps case managers catch problems early on.

“Frailer, older adults who are sick often don’t present in the same way that younger people do,” Gleich says. “Younger, healthier people with pneumonia will cough and be short of breath, but an older, frailer person with pneumonia might stop eating or moving around as much.”

For older and frailer adults, the illness is more of a total body illness rather than a localized sickness, he explains.

Case managers found that some people thought the technology too intrusive, particularly when they received calls based on their activities, Briggs says.

Others liked having something watching out for them or didn’t even remember it was there, she adds.

“Many have a sense of security, knowing that if something happens there will be someone who checks up on that,” Gleich says. “There’s a sense of security for some people.”

The pilot project studied a group of seniors who used the technology and compared their health results with a control group that did not, Gleich says.

“We looked at the two groups to see if they were similar, and we looked at the utilization of medical services and home care services,” Gleich explains. “We found a cost savings associated with people who had Healthsense, compared with the control group.”

The intervention group had higher spending on home health services, which could have resulted from case managers picking up on problems that require a home health visit. But the intervention group also spent less on ED visits, hospitalizations, and long-term placement, Gleich adds.

The use of technology to monitor frail elderly people’s activities adds another layer to overall case management, Gleich says. “It’s about prevention and picking things up early, which is effective case management.”

NaviCare’s transition of care program provides member follow-up after any inpatient stay and discharge to home. Patients are called or visited within 48 hours of discharge, and their care management includes medication reconciliation and an overall assessment of medical and functional status, Briggs says.

“Then we update their care plan and communicate that to their primary care provider,” she says.

Other case management activities under NaviCare include follow-up on ED visits.

“We look at high utilizers of the emergency department and develop individualized plans for reducing their ED visits,” Gleich explains. “The individualized and coordinated plan involves behavioral health and education about medical conditions and having more appropriate places to receive care when there’s an emergency.”

NaviCare also offers medication reviews for plan members on high-risk medications. A pharmacy team reviews their prescriptions and partners with primary care providers to make certain the medications they are taking are the best ones for them, Gleich adds.

“Some provider groups have embedded navigators, which is another role within our program,” Briggs says.

Other case management services offered to plan members include benefits that tackle healthcare social determinants of health, including providing members with rides to medical appointments and to shopping venues and senior centers. The program assists with the purchase of eyeglasses, hearing aids, and other things that are not covered under traditional government insurance, Gleich notes.

“And starting in January, we’re partnering with the Alzheimer’s Association to go out to each patient who has dementia to do a comprehensive care plan,” Gleich adds.