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Close relationship with patients is key to success
Health plan employees part of primary care team
Sonia Hoffman, RN, BSN, a Geisinger Health Plan case manager who works at a primary care clinic, tells the following story of how her interventions kept a woman with severe chronic obstructive disease out of the hospital and avoided unnecessary utilization of health care resources:
As part of the treatment team at the primary care practice, Hoffman had worked with the woman for four years when the woman was diagnosed with aortic stenosis. Because of the severity of her condition, she couldn't have surgery to correct the problem, which intensified her health care needs.
The woman had a stay in a nursing home but wanted to go home so Hoffman developed a transitional care plan to provide home health services in the woman's home.
By talking with the patient and her caregiver three or four times a week and adjusting her medications weekly, Hoffman was able to keep the patient out of the hospital.
"Early on, I started talking with the patient and family about options for care. The physician and I went to the home on two occasions to discuss options, but she wasn't quite ready for hospice care," Hoffman says.
When the patient's condition worsened and she went to the emergency department, Hoffman faxed the woman's living will and power-of-attorney to the hospital and informed the case manager and the emergency department physician about the woman's history and condition.
"There was nothing that could be done for her medically, and she didn't want to be admitted. We were able to get her home and work with the home health nurse and the area agency on aging to get her the care she needs," Hoffman says.
Without an intervention, the patient would have gone into respiratory distress, been admitted, and possibly had additional services that she really didn't want, Hoffman points out.
"That would not have been the best utilization of resources, and it wasn't what the patient or her family wanted," she says.
Since Hoffman works with patients in the doctor's office, the patients and family members don't identify her as part of the health plan, Hoffman says.
By being in the doctor's office, Hoffman develops a rapport with patients and their families when they come to see their physician.
"They identify me as a caregiver who has their best interests at heart, and I see many of them on a regular basis. My office is directly across from the lab and they know where to find me," she says.
When new patients are identified for the program, Hoffman does a chart review and learns as much as possible about the patients before calling them and explaining what her role is.
If patients are admitted to a hospital, Hoffman works with the hospital case management team to develop a plan of care and is alerted when the patient goes home. She follows up with a call within 24 to 48 hour, Monday through Friday. The case managers rotate weekly duty and have on-call services 24-7.
"If a patient I've been working with is going home on Friday, I call them the next day. If it's a new patient going home on Friday or Saturday and I see red flags that may indicate gaps in care, like a patient with a wound who doesn't have home care services, I notify the inpatient home health services or I refer them to the health plan on-call case manager," she says.
Physicians often call Hoffman into the exam room when a patient needs services such as home health. In those instances, she double-checks on the insurance plan and conducts a brief chart review. If the patient does not have Geisinger Health Plan insurance or Medicare, Hoffman will provide directions for the office-based nurse so that all patients have access to the resources they need.
"I talk with the patient, identify their problem, take care of the acute problem, and call them the next day to review the patient's plan of care and social needs and to identify their barriers to adhering to the plan of care," she says.
She follows up as frequently as necessary depending on the patient's needs. Patients who have been discharged from the hospital receive at least one phone call a week for four weeks. If they have a lot of complex needs, Hoffman calls them two or three times a week.
The model also uses an outbound telephone monitoring system that makes phone calls to discharged patients with no comorbidities, such as a younger patient who had a total knee replacement. The interactive voice response system asks patients if they are having problems and gives them a number to call.
"This helps maximize the skills of the nurses. The case managers are taking care of the people who are at highest risk, but we have a way to reach all patients," Tomcavage says.
Some patients are going through a rough period when they enter case management and become an inactive case when their acute needs have been handled. They always have their case manager's telephone number to call in case they have problems.
For instance, if a patient calls in and says he has a cold, he's not likely to get an appointment, but the case manager can intervene if it's a person with lymphoma who has a suppressed immune system and get an immediate appointment for the patient.
Patients with chronic illnesses, such as heart failure or COPD, typically stay in the case management program. If they have tobacco issues, diabetes, osteoporosis, hypertension, or other diagnoses and have their conditions under control, the case manager puts them in touch with a disease management program to provide telephone follow-up.
Hoffman has met almost all of her patients face to face at least once, the exception being patients who are in a nursing home.
"I don't go to the nursing homes often except for a care planning meeting when sensitive issues are being discussed; but I do work with the care team at nursing homes to make sure they have all the information they need for a smooth transition and to make sure the patient's needs are being met."
Home visits are not the norm, but Hoffman visits her patients when she feels that it's needed.
"My job is all about building a relationship with them and earning their trust so they understand that I truly have their best interests at heart," she says.