Critical Path Network

Project to reduce costs for Medicare beneficiaries

Hospital places CMs in primary care offices

After three years, Massachusetts General Hospital's Medicare demonstration project to manage the care of high-risk, high-cost Medicare patients appears to be making a difference for many medically complex patients, according to Joanne Kaufman, RN, MPA, A-CCC, nurse manager for the care management program at Massachusetts General.

The Centers for Medicare & Medicaid Services (CMS) has approved expanding the program to include two affiliated Boston-area hospitals and has extended it for another three years. CMS has contracted with RTI International to conduct an independent evaluation of the program's effectiveness in improving quality of care and reducing Medicare expenditures.

The MassGeneral care management program, which started in 2006, is a primary care-based model designed to coordinate care and improve transitions as patients move through the continuum of care.

When the program began, CMS provided the hospital with a group of 2,600 patients and selected a comparison group of patients with similar medical risk and utilization, says Mary Neagle, project manager, MassGeneral care management program.

"The overall goal of the project is to improve care in a variety of ways by working closely with patients in a primary care practice and by helping patients navigate the complicated health care system," Kaufman says.

The hospital receives a monthly fee for each participant in the program and must achieve a savings target that includes their fees.

"The program is a financial risk for the hospital and Massachusetts General Physicians' Organization, but everyone from the CEO on down supports the initiative to help improve care for Medicare beneficiaries," Kaufman says.

The case managers in the program are assigned to primary care practices and work in the practice setting. They collaborate closely with the physicians and the care team to ensure that the patients' health care and psychosocial needs are met.

Patients in the program live in the Greater Boston area and are being treated by a primary care physician who is in the hospital's health system.

"These are the sickest of the sick patients, and the physicians know them very well. We work with the patient and his or her primary care physician to develop a plan of care. We facilitate referrals to community and home-based services such as skilled home care and transportation to appointments that can help the patients stay as safe and healthy as possible," Kaufman says.

Depending on the number of patients in a practice, some physician groups have more than one case manager assigned to them and others share a case manager with another practice.

"Prior to the start of the program, we piloted a similar model in one primary care practice. This provided tremendous insight and helped form the model we now are using," Neagle says.

Before the program began, the project team visited the physician practices to learn about the needs of their patients and how the program could best collaborate with the practices to address the patients' needs.

"We negotiated with them to provide space for our case managers and worked on building relationships with the physician, nursing staff, and other employees of the practice," she adds.

Most of the patients in the program have several chronic diseases and may have either a mental health diagnosis or psychosocial needs, or both, Kaufman says.

"We knew up front that we needed a mental health component and a social worker on the team. In the fourth year, we have three social workers whom the case managers can call on to co-manage patients with a mental health diagnosis or a psychosocial need," she adds.

The social workers are assigned by primary care practice so each case manager has a "go-to" social worker. They receive referrals when patients need psychosocial support or make "friendly phone calls" to the patients to remind them of appointments and check in to make sure they're doing well.

So the case managers could concentrate on the clinical needs of the patients and handle a larger case load, the Massachusetts General team created the position of community resources specialist , a nonclinical person who helps with transportation, housing assistance, access to community services, and other non-medical issues.

When patients are chosen for the program, CMS sends a letter introducing the program.

The case managers review the medical records of their assigned patients, then meet with the primary care physicians to get additional information and to prioritize the patients as high, medium, or low risk.

They call each patient, enrolling those who are willing to participate, and conducting an assessment to identify their needs. Areas covered by the assessment include functionality, psychosocial needs, transportation needs, and medication.

As part of the assessment, the case managers identify caregivers and family members so they can communicate and collaborate with them if any issues arise.

"It may be that they haven't been in to see the physician in a while and need an appointment or need transportation. If a patient is coming into the emergency department frequently with shortness of breath related to heart failure, the case manager may set up skilled nursing visits to monitor the patient or may arrange for telemonitoring," she says.

They work with the patients to set goals and look at what resources patients need to meet the goals.

For instance, they may make a referral to a social worker for follow-up if a patient is experiencing depression or contact the community resource specialist to set up transportation to a physician visit, or ask a pharmacist to evaluate the patient's medication.

"When all those pieces are put into place, the case manager follows the patient through the continuum and bases the frequency of the follow-up interventions on patient needs," Kaufman says.

The case managers get a list every week of patients who have appointments with the primary care physicians. They also get a list of patients who have canceled or missed their appointments and follow up to find out the reason the patient missed the appointment and reschedule a visit with the physician. They frequently meet with the patients when they come in to see their primary care provider.

The case managers work with patients in the program to ensure that they have advance directives in place and can provide copies to the inpatient team.

When patients visit the emergency department or are hospitalized, the case managers are automatically notified.

"We rely heavily on our electronic system to help us coordinate the care of these patients and to communicate with providers," Kaufman says.

For instance, when a patient in the program is admitted to Massachusetts General Hospital, the case manager sends an electronic note to the hospital case manager with information about what has been going on with the patient in the primary care setting.

"Some of our patients and family members have challenging psychosocial issues and complex family dynamics, and it helps when the primary care-based case managers can provide the hospital team with information on the patient's medical history, social support, and how to best approach issues with them," she says.

The MassGeneral care management case managers meet with patients in the hospital when possible and often attend family meetings with the hospital team if critical decisions about the patient's care are being made. Sometimes they participate by telephone so they will be available to give input and answer any questions the team may have, Kaufman says.

When a patient is discharged from the hospital, the case manager makes a follow-up call within 24 to 72 hours and completes a post-discharge assessment to make sure the patient is settled back into the community, has filled his or her prescriptions, and has a follow-up visit with a primary care physician. The case manager also makes sure that any durable medical equipment has been delivered, and that a home health practitioner has visited if the physician has ordered it.

The post-discharge assessment includes questions about whether the patients know why they were in the hospital and if they called their primary care physician before going to the emergency department, Kaufman says.

"We try to reconnect the patient with their primary care provider and gather any critical information the primary care physician needs. We make sure that the patient's follow-up appointment is timely. If the date is more than a week away, the case manager makes sure the patient gets an appointment sooner. If a patient is having problems with medications, the case manager works with the primary care physician to clarify the medication regimen," she says.

The team members have developed close relationships with community organizations, home care agencies, skilled nursing facilities, and hospice care agencies.

"Our patients often have needs for community and home-based services. We want the providers to have an understanding of our program and what our goals are so we can collaborate with them on care," Kaufman says.

The case managers reach out to skilled nursing facilities, rehabilitation hospitals, and other post-acute providers to let them know that their patients are part of the program and to make sure they received the appropriate paper work. They get an estimate of when the patient is likely to be discharged from post-acute care and they help facilitate the transition back to the community.

If a patient goes home with home care services or is receiving hospice care, the case manager shares this information with the physician and other members of the patient's care team.

"We follow the patients throughout the continuum and try to help coordinate their care. As advocates for our patients, we want to make sure their needs are met at every level of care," she says.

This year, CMS has expanded the program to Brigham and Women's/Faulkner Hospital and Northshore Medical Center.

As the program has progressed, the team has analyzed data and made operational changes.

"This is not a stagnant program. We review data and talk with staff every step of the way to determine what is working well and to identify opportunities for improving the model. The program is ever-changing, and as a result, in the future it probably will look somewhat different from today's model," Neagle says.

[For more information, contact: Mary Neagle, project manager MassGeneral Care Management program, e-mail:]