Wireless technology connects case managers with referral sources

Community agencies join to serve the uninsured

Thanks to wireless technology, case managers working in Chicago’s poorest neighborhoods no longer have lengthy waits to get referrals to other agencies for their clients.

Now, when they locate a client or potential client in the field, they have instant access to information about that person and can be in immediate touch with other community agencies that provide services to the medically underserved.

Access Community Health Network, Chicago’s largest provider of community-based primary health care, created a technology-based adherence program with a grant from the U.S. Department of Commerce.

Access Community Health operates 40 health centers in Chicago and its suburbs, providing primary preventive care and HIV case management to 300 HIV-positive patients.

The system links Access with seven other community agencies that make up West Side Collaborative Care, a coalition formed to increase access to health care for people at risk of HIV/AIDS and other sexually transmitted diseases, tuberculosis, and substance abuse disorders.

The Client Adherence Referral Electronic (CARE) system integrates a case management referral and tracking software system with wireless sub-notebook personal computers and special message-routing technology.

Coalition members can access the software in the office, at home, or in the field with their wireless sub-notebooks. Case managers in the field have instant access to client information on the computer. They can enter or access client demographics and assessments and make referrals on the spot. The data they collect in the field are wirelessly uploaded into the master database for immediate client update.

Using the CARE system, case managers can send a referral to a community agency and get back an answer within a few minutes, rather than making multiple phone calls and faxing pages of documents back and forth.

"One of the barriers to delivering community-based health care in the field is timely communication. This system allows all of the agencies to track referrals of clients and share key information essential to coordinating care and promoting adherence to referrals and treatment plans," says Angelique Johnson, director of grants management for Access Community Health.

The wireless technology has helped community-based case managers cut referral times from a few days to a few minutes and has helped the agencies eliminate client "double-dipping."

The agencies have experienced a 75% increase in case management efficiency, Johnson says.

The web-based software unifies intakes and referrals from the various agencies and creates one client file shared by the participating agencies, says Abe Miller, information services manager for Access Community Health Network.

"The software includes a built-in history system, allowing the case manager to view past referrals for services, assessments, and changes to client demographics," Miller says.

Before the CARE system was created, representatives from the eight different agencies collaborated to determine what data the system should collect, with each agency listing the minimum amount of information it needed from an assessment to decide whether to accept or decline a referral, Miller says.

The group came up with 22 questions that every agency uses for its assessment process.

Once a client is in the system, if he or she goes to a different agency, that agency can see demographic information, past intakes, assessments, and referrals.

The case managers who work in the field for all the participating agencies take wireless touchscreen sub-notebook computers with them when they go out to see clients.

They enter clients into the system, complete an assessment, and collect a medical history. If the patient is receiving services from one of the eight agencies and is in the system, the case manager merely updates the file.

Each agency in the collaborative has a two-way pager with a mini-keyboard. The pager numbers are already in the CARE system for each agency. Case managers use this system to facilitate referrals.

For instance, when a case manager encounters a client who needs substance abuse treatment, she enters the information into the system on her computer and gets a list of all the agencies that provide the service.

She chooses the agency that best fits her client’s needs, such as a program for females with children, enters notes into the computer system, and conducts an on-line referral in real time.

The system automatically pages the agency by sending a text message on the two-way pager. Then someone from the agency logs into the CARE system web site and has access to client demographics, intake information, and assessment. The system gives them the option to accept the referral, decline the referral, or put the client on the waiting list. Then the system pages the case manager with the decision. "We’ve been able to reduce the time we spend communicating back and forth and automate our referral process," she says.

Case managers working in the field need to quickly and easily connect clients with housing, food, and other nonmedical needs, as well as ensuring that they get physician appointments when they need them, Johnson says. They spend most of their time in the field looking for their clients, most of whom are homeless.

Access case manager Katrina Holmes is a specialist in HIV and AIDS prevention case management, Johnson says. When Holmes and other case managers go out with the Chicago Recovery Alliance’s needle exchange van, they look for people who would be appropriate for case management and approach them cautiously about seeking medical care.

"Katrina gives out condoms and talks about HIV prevention and gradually builds up a rapport with the clients. Instead of immediately focusing in on their health care needs, initially she works on becoming a friend," Johnson says.

After they build up a rapport with the people, the case managers try to strike up a conversation to open the door to providing additional services.

"A case manager might say, It seems like you don’t feel well. Would you be interested in coming by the health center? I can schedule an appointment for you now,’" Johnson says.

Recently, one case manager in an outreach van reported that it took less than 20 minutes to make a referral for a new client and receive a response. It took five minutes to add the client into the database, seven minutes to do an assessment and make a referral, and another five minutes to receive a response.

"Before the CARE system, there was a huge gap in communication between one agency and another. There would be requests for information on referrals and service availability back and forth. Sometimes a case manager had to talk to several agencies and wait for a response. This has dramatically impacted service delivery," Johnson says.

In the past, Access case managers would have to write down demographic information and assessment information, then call a treatment center looking for an open bed.

"The problem was trying to get someone. They had to leave a voice mail message or try to page someone in the other agency. It would be hours or sometimes even days before they’d get a response," Johnson says.

The system is particularly helpful in facilitating referrals for a clientele that is transient and likely to change their minds about getting treatment, Johnson points out.

In a typical scenario, a case manager will encounter a client when she’s with the Chicago Recovery Alliance. Often the case manager and client have talked for weeks or even months about treatment services, and one day the client is finally ready.

Quick referrals can make the difference 

"When they say they’re ready to go into treatment, if you have to wait a day or even a couple of hours, you’re likely to lose them," Johnson says. "Unless you get someone into treatment right then and there when they say they’re ready, 95% of the time you can’t find them again."

When the case manager gets a timely answer to the referral, she can arrange transportation to the treatment center and get the clients there before they change their minds.

The system has helped agencies eliminate double- and triple- "dipping" by clients who go to more than one agency for free food and medication.

"If someone is getting food or medicine from several different agencies, they’re taking it away from the people who really need it. Before we had this system, there was no way for the other agencies to know where the client was getting services," Johnson says.

For instance, recently a man showed up at Haymarket Center asking for HIV case management and a referral for medical services and housing. When his name was put into the system, it showed that someone with the same name and date of birth was receiving services from Access Community Health.

The Haymarket case manager talked to his case manager at Access, confirmed he was getting services there, and asked the client to choose which agency he wanted to provide the services.

The coalition currently has a software-integrated reminder system in the pilot-testing stage. Within the CARE system, pagers can be set up to send reminders to patients who have a hard time remembering medications or to remind them when they need to come in for medical appointments or group therapy meetings.

"We have HIV patients who have to take medicine multiple times a day. It’s often hard to remember to take it every time," Miller says.

The system allows the case manager to pull up the client’s file, enter a pager identification code, and set up a reminder. The software prompts the message-routing system to send individualized messages to clients reminding them of appointments or to take their medication, or sending them words of encouragement. Clients can instantly respond to the message, choosing from a list of customized responses. For instance, with medication reminders, the system asks clients if they took the medication, if they need a refill, or if they want the case manager to call them.

The coalition recently gave out 35 two-way pagers to clients to test the system. Early results of the pilot program show that it is working and that clients like it.

"The message is getting out to the clients, the clients can respond, and we can track the responses. We’ll be able to look at actual laboratory results and compare them to a client’s message response log to see if we are getting increased adherence to the client’s treatment plan," Miller says.

The system is capable of sending special messages to remind people of their appointments either through the pagers or through an automatic telephone message system, which Miller hopes to test in the future.