EXECUTIVE SUMMARY

Health advocates provide case management-style services in the private sector, helping patients maintain health and mobility in home settings or managing care transitions.

  • Families sometimes hire health advocates to help their loved ones navigate medical challenges and transitions.
  • Goals include optimizing patients’ health and quality of life.
  • Health advocates work with health facility case managers, utilization review managers, and payers.

Case managers work with patients across the care continuum, and their roles and titles vary. But one of the lesser-known models for case management is in private pay, where they are known as health advocates or patient advocates.

It is a growing field, as patients and families often find it difficult to navigate the complex healthcare continuum. Health advocates provide case management-type services with their chief goals related to patients’ needs. Typically, their work is funded by patients and patients’ families.

“When I started LifeSpan Care Management 15 years ago, the term ‘health advocate’ wasn’t used,” says Michael Newell, RN, MSN, founder and president of LifeSpan in Haddonfield, NJ.

“My model is the same as a field case manager who is working for a private rehab company or a workers’ compensation insurance company,” Newell says. “We see patients, following them through their course of treatment until they reach maximum improvement, or the client says, ‘I don’t need you anymore.’”

The health/patient advocate model involves case managers paying attention to what the client wants. Often, it is a patient’s family that might hire a health advocate to help navigate their loved one’s health challenges.

“We usually have families calling us,” says Bobbi Kolonay, RN, BSN, MS, CCM, president of Holistic Aging & Options for Elder Care in Pittsburgh.

“Unfortunately, when families have reached the point where they are so overwhelmed or don’t know what to do, that’s the typical call we get,” Kolonay says. “About 15% call for a preventive role, but the majority call when it’s a crisis and they really don’t know what to do.”

Since Kolonay started the company about two decades ago, it has grown from one employee to 14 employees. The patient advocates are case managers with nursing backgrounds, she says.

The health advocate model is clinician-driven, Newell says.

“We’re paying attention to the details of what the medical issues are and to optimize the client’s functionality of life, using tools that are at a case manager’s disposal,” he explains. “These tools include rehab tune-ups, adaptive equipment, referring to specialty providers, referring to nontraditional providers — all based on what the client wants, needs, tried before, or what might help them.”

Patients with a personal advocate receive help scheduling and attending doctor’s appointments, filing insurance appeals, benefiting from care conferences, and coordinating discharges, he adds. (See story on health advocates services in this issue.)

Case managers typically see patients who have chronic and complex illnesses and are at risk for hospitalizations and ED visits. Their goals are to help these patients become stable medically and improve in their self-care.

Health advocates provide additional customer service to the case management role, Newell says.

“The customer service piece in healthcare is so ragged that a lot of times patients aren’t heard, or they are promised things that do not happen,” he says.

For example, Newell regularly sees patients who should have been told about palliative care, but this topic is ignored.

“In one case, the patient was in subacute care and hadn’t made any progress in 28 days, and the family was told to send him to a nursing home,” Newell recalls. “We addressed palliative care and assisted the patient and family to work through those issues, and they went for this option.”

The family was relieved to have an option that did not hinge on a recovery that might never occur. “Palliative care is a difficult conversation to have, but at the end, they were relieved because they could see that they’ve done everything they reasonably could do,” Newell explains.

Health advocates can see any patient at any point in their medical and cognitive status. For instance, most patients at Holistic Aging experience cognitive problems. Most are older than age 80 years and live alone, Kolonay says.

“Their children might have tried to pull in external caregivers, but there’s no one managing them,” she says. “When we work with them, we develop a very trusting relationship.”

The goal is to help patients remain autonomous, but know they have someone looking out for them.

From a case manager’s perspective, the health advocate’s role includes a business aspect.

“No matter what setting you’re in, you have to work it like a business,” says Jeanne Stanton, RN, BSN, MHA, LNHA, care manager at LifeSpan Care Management.

Not all case managers and healthcare providers think in those terms, but private-pay case management roles have to be economically sustainable. They need to show that what they do helps other healthcare providers sustain their business interests as well, she notes.

When health advocates recognize other providers’ interests, it builds good will. “They’ll come away talking about it in a positive way, and you’ll get more business,” Stanton says.

Health advocates often begin their interactions with patients in the hospital or skilled nursing facility following a medical crisis.

“A typical example is a patient who was living alone, fell in the house, broke a hip, and went to the hospital for surgery,” Newell says. “Then, the patient goes to a nursing home for subacute care and has been there about three weeks when the family is notified that Mama is going to be discharged in three days, and they know Mama isn’t ready to go home.”

The patient is unable to engage in rehabilitation, is experiencing shortness of breath, and there is not a good plan for home care. That is when the patient’s family calls in a health advocate.

“We assess that person, and, more often than not, there are some unresolved medical issues that haven’t been taken into consideration in terms of ending the rehab,” Newell explains.

The health advocate can discuss the patient’s situation with the facility’s case manager or utilization review manager and/or with payers to see if the patient’s planned discharge might need to be changed.

“I want to see the denial of further treatment on paper, not verbally,” Newell says. “That will slow down the process, typically delaying the discharge for about a week until these things are addressed.”

The problem that health coaches help solve is that years of speeding up discharges have led to low expectations for patients’ functional skills. If patients meet these minimal criteria, they are told to go home, even if they are in no condition to return to their daily activities, he says. InterQual Level of Care criteria that determine a patient’s required level of care might not be documented adequately.

“We’re aware of those criteria and refer to it when we address a discharge that we feel is premature or inappropriate,” Newell explains. “To discharge a person to home under Medicare guidelines, you need a willing and able caregiver, and it needs to be a safe discharge. Often, that doesn’t happen.”

The health advocate’s goal is to remind the facility’s case manager, social worker, or physician about the standard for Medicare discharges, he adds.

“We’re a little different than a hospital case manager or insurance company case manager in that we act as fiduciary,” Newell says. “A fiduciary is someone who takes responsibility of advising their client, based on what they think is best for their client and what they would do for themselves or their loved ones.”

Gaining extra time before the patient is discharged has two potential benefits:

  • Giving the health advocate and providers an opportunity to ensure the patient will be safe to return home;
  • Giving the patient’s family time to arrange for obtaining any necessary help in the home.

“The family might still be stuck in thinking, ‘I can’t believe Mom fell and broke her hip,’” Newell says. “They think it’s a one-off. But, no, the fact that mom fell and broke her hip means that we have to get her back to her previous level of functioning, which she might not be able to do, but she’s at risk for another fall.”

The health coach will help family members assess the patient’s home to look for risks that might cause the patient to fall again, he adds.