CMs help seniors understand treatment plans

Medicare project increases quality, cuts costs

When selected Medicare beneficiaries being treated at University of Michigan Health System facilities are discharged from the hospital medical unit or treated and released from the emergency department, case managers at the University of Michigan Faculty Group Practice Medical Management Center call them to make sure they have follow-up appointments and that they understand their treatment plan.

The initiative is part of the University of Michigan Health System's efforts to provide quality care at a reduced cost through the Centers for Medicare & Medicaid Services' Group Practice Demonstration Project, which rewards physicians for providing high-quality care.

"Case management is just one piece of the project," points out Donna Fox, RN, health services manager and case manager for the Medical Management Center at the University of Michigan Health System.

The program targets about 20,000 traditional Medicare beneficiaries who receive nearly all their care at University of Michigan facilities. Medicare Advantage members or those who receive only limited care from the health system are not included.

The practice, part of the University of Michigan medical school, includes all 1,500 faculty physicians who care for patients at three hospitals and 40 health centers operated by the University of Michigan.

The purpose of the follow-up calls is to prevent patients from being readmitted to the hospital or visiting the emergency department by eliminating the gaps in care that often occur between the time patients are discharged from the acute care hospital and when they make follow-up visits to their primary care provider.

"One of our goals is to make sure patients are not at home and getting sicker because they are confused about their medication or their treatment plan," Fox says,

Case managers attempt to get in touch by telephone with all patients on the medical units who have been hospitalized for non-elective episodes of care as well as patients who have received vascular procedures, such as catheterization and stents.

The case management team receives a list of patients being discharged from the hospital each day.

"We review the cases and eliminate those who are discharged to a skilled facility or those with diseases such as end-stage renal disease or those who have a cancer diagnosis with a treatment plan. We know they are already being case managed by others," Fox says.

The demonstration project targets patients who receive the bulk of their care from the University of Michigan Health System. Most live within an eight-county area but if patients who live further away get most of their care from the health system, the case managers call them as well.

If the patients are seeing a primary care physician who practices outside the health system and the medical record indicates they need a quick follow-up visit, the case managers ask the patients for permission to call their doctor and make him or her aware that the patient has been hospitalized and needs a follow-up appointment in the next few days.

The case managers typically make follow-up calls to about 70 patients a day. Mondays are the busiest because they are calling patients who were discharged from the hospital or visited the emergency department on Friday, Saturday, and Sunday.

If the patients have been hospitalized, the case managers go over the discharge summary with them and explain the treatment plan. They make sure the patients understand their medications and how to take them.

"When patients are discharged from the hospital, they often have numerous bottles of pills they were taking before admission as well as new prescriptions. We go over the medications and help them understand what to take and what not to take. Medication reconciliation is a huge piece of what we do," Fox says.

If patients are confused about their treatment plan, the case managers can call the attending physician or the discharging physician if appropriate for clarification.

"I always tell the patients to take all their medications with them to their next doctor's visit and to ask the doctor to go through them and determine which ones they should be taking," Fox says.

The case managers talk to the patients about the importance of getting their prescriptions filled and make sure that they are able to afford to get them filled.

The case managers access the health system's electronic health record to determine what upcoming appointments the patient has and discuss them with the patient. If patients have not scheduled an appointment or can't go to the one scheduled, the case managers assist them in scheduling or rescheduling an appointment.

"We can set up a conference call with the doctor's office while the patients are still on the phone. This works best because we can take care of transportation issues and scheduling right on the spot," she says.

When Medicare patients targeted in the demonstration project have visited the emergency department, the case managers contact them to make sure they have rapid follow-up with their primary care physicians.

"Sometimes patients end up in the emergency department because their condition got worse during the hours when they couldn't make an office visit to see the doctor. We make sure they get in a cycle of seeing their physician regularly and avoiding an exacerbation that sends them to the emergency room," she says.

Patients who can't get in to see their primary care physicians can be seen at the Turner Geriatric Clinic's transitional care clinic, designed for patients who are post-discharge.

"It's best if they can see their primary care physician because that doctor knows them best. If not, we get them into the transitional care clinic to make sure they see someone," she says.

The transitional care visits typically are longer than regular physician visits and may involve a social work assessment.

"It's a great visit for patients coming out of the hospital. They aren't rushed. The providers review all the medications and talk to the family to make sure the patient has everything he or she needs to follow the treatment plan and stay healthy at home," she adds.

When they talk to Medicare beneficiaries on the telephone, the case managers assess their psycho-social and socio-economic needs and their support system at home in the community.

"We ask who helps them at home, if they are able to get their own meals, and if they need assistance getting their prescriptions filled. Community support is a big issue for seniors because they want to be independent and live in their own home. If they have problems, we talk to them about accessing community resources that can help meet their needs," she says.

The case managers often ask the seniors for permission to speak to family members if they feel there is a problem and follow up with the family to make sure they are aware of all the issues facing their loved ones.

"Sometimes the seniors are too proud to admit that they need help with everyday tasks or that they don't have the money to pay for food and medication. We make the families more aware of their needs and work with them to find community resources that can help," she says.

The case managers make referrals to the visiting nurse agency if they feel the patient is unsafe at home or that something has been missed.

"Sometimes we'll assess a patient on the phone, and they are so confused about their medication and other parts of their treatment plan that we ask for a visiting nurse to visit and the doctor signs off on the referral. Our goal is to keep these patients from going back to the emergency department," she says.