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CMs in primary care practices facilitate care for at-risk members
Pilot demonstrated a 20% reduction in hospital readmissions
Geisinger Health Plan's patient-centered medical home pilot project, which placed case managers in primary care practices, reduced hospital admissions for heart failure, pneumonia, chronic obstructive pulmonary disease, and the frail elderly within six months, and ultimately demonstrated a 20% reduction in hospital readmissions.
After the initial success of the pilot, the health plan has expanded the program, called the Geisinger Health Plan Health Navigator and now has 61 embedded case managers at 37 practice sites who coordinate care for 40,000 Medicare beneficiaries and 2,500 commercial members, says Janet Tomcavage, RN, MSN, vice president of health services for the Danville, PA-based health plan.
The initiative calls for one case manager for every 700 to 800 Medicare beneficiaries or 5,000 commercial lives.
The program continues to achieve a 15% to 20% reduction in hospital readmissions for the entire practice, and not just for the patients in case management, she adds.
"We believe that the success of the medical home program has been because of the value case managers bring to the highest-risk population. We believe that by managing a small percentage of the Medicare population in a practice, case management can drive unnecessary utilization and medical expenses down for the whole population at that practice," Tomcavage says.
The case managers are hired, trained, and supervised by the health plan and are embedded in the primary care practices and function as a part of the primary care team. They coordinate care for the highest-risk patients and facilitate the transition of every patient from hospital to home or a nursing home.
Geisinger Health Plan began developing the program in 2006 to combat the growing burden of chronic disease, the fragmentation of care, exploding health care costs, gaps in quality, and the decline of the work force in primary care, Tomcavage says.
The initiative kicked off in January 2007 at two sites with three case managers who coordinated care for about 3,000 Medicare beneficiaries.
"When we started the program, we looked for opportunities to change the way we approach people with complex medical conditions to address gaps in care. Fragmentation, lack of coordination of care, and quality was a real concern. As an insurer, we knew that we could not continue to pay using the work-unit mentality. We wanted to design a payment model to pay for outcomes, rather than individual work units," she says.
Geisinger Health Plan has had a robust disease management and case management program for 15 years, says Sonia Hoffman, RN, BSN, case manager in a primary care clinic.
"We had a lot of expertise and had poured a lot of resources into strategies for managing the care of patients with chronic conditions and complex medical needs. We knew that if we pushed some of our disease management and case management strategies into primary care, we could make a difference," Hoffman says.
Geisinger is an integrated system that includes hospitals and outpatient clinics in addition to the health plan.
Geisinger's program combines the strengths of the health care delivery model with the strengths of the health plan to form a partnership that drives outcomes for individual patients as well as improving clinical and financial outcomes, Tomcavage says.
The health plan team collaborated with leadership at the primary care practices to create the model and redefine roles within the health care team to improve efficiency and effectiveness.
"The basis of patient-centered primary care is moving people to the top of their license," Tomcavage says.
This means having physicians do what only physicians can do, nurses doing what only a nurse can do, and moving other tasks to a non-clinical person when appropriate.
"We looked at roles and activities best suited to each discipline and maximized health information technology by designing tools that help a physician practice manage its population," she adds.
Before launching the program, the health plan did a lot of groundwork in forging relationships with providers throughout the continuum, Tomcavage says.
"The primary care office is the foundation for much of the activity involving patients but is just one piece of the health care system. The hospital, the emergency room, specialists, the community pharmacy, home health agencies, and other post-acute providers are all a critical piece of managing patient better and driving better outcomes," Tomcavage says.
For instance, many times when patients came back to see their primary care physician after being in the hospital, the doctor didn't have the discharge summary or had to struggle to read the handwritten notes.
The team worked with the hospitals to get timely discharge summaries in a readable form. They worked with community pharmacists on getting pill boxes pre-filled and prescriptions delivered.
"We collaborated with home health agencies on managing patients in a different way. If we needed them at a particular time, we wanted them to be available to make the visit and to work with the clinic-based case manager to assure effective transitions," she says.
Recognizing that one in three Medicare patients in nursing homes are readmitted to acute care, the case managers work with the core nursing homes in the community, round with the physicians, and participate in family conferences when needed.
"The case managers work extremely hard when patients transition into nursing homes to make sure they get continuity of care," Tomcavage says.
The case managers coordinate care between the specialist and the primary care physician and help the patients understand their treatment plan.
For instance, a patient with heart failure and declining kidney function may be told to drink a lot of fluids by the nephrologist and to keep their fluid intake down by the cardiologist.
"Sometimes there are conflicting messages. The case manager translates them into something the patient can understand," Tomcavage says.
When the health plan rolls out the Health Navigator program at a primary care site, the practice uses the health plan's predictive modeling tool to profile its population and identify patients who are at low risk, moderate risk, and high risk for health care consumption.
The case managers at the practice sites get a list of patients in the program, sit down with the physicians, and look at the risk stratification of each patient, then develop strategies to manage their care. The higher-risk patients are enrolled in case management.
"This helps us identify patients at risk and those who have preventive care needs. Some patients haven't been in to see their primary care provider in more than a year and have gaps in preventive care. Others have chronic conditions and need education and other resources," she says.
Other patients are identified for the program by their physician or when they have been hospitalized.
Having case managers in a primary care practice helps eliminate the tendency on the part of patients and physicians to think of the health plan as an outsider, not part of the care team, Tomcavage points out.
"The embedded case manager becomes an extension of the primary care practice team, and both patients and providers trust the case manager and realize that he or she knows what is going on and that there are additional resources to help patients and their families navigate through the often complex health care system," she says.
Over the four years she's worked in this model of care, Hoffman has had only two patients refuse to participate.
"If patients are suspicious in the beginning, the physician intervenes and tells them to consider the case manager a direct link to the physician. Once they get involved with the program, they realize they can call my private number and get in to see the doctor whenever they need something," Hoffman says.
The health plan works with each Health Navigator site to pick 10 quality metrics to measure. Examples of the quality metrics include: the percentage of patients who have a follow-up call from a case manager within 48 hours of discharge; the percentage of patients who have a timely post-discharge follow-up visit with their physician; preventive care measures such as mammograms or flu shots; the percentage of heart failure patients who have an action plan documented in their medial record; and the percentage of patients with diabetes who receive the appropriate care.
Part of the physician practices' reimbursement is based on their performance on the core quality measures.
When the health plan began the model, it kept fee-for-service reimbursement and its pay-for-performance initiative in place based on HEDIS data and other measures but added an efficiency target to the payment structure and shares 50% of the cost savings with the practice, based on how many of their quality indicators were met.
For instance, if a practice beat its cost target by $100,000, and met five of its 10 quality measures, it would receive an additional $25,000 in reimbursement.
"We didn't want the practices to be at risk. We wanted to reward them for delivering high-quality care in a more efficient manner. We believe that if you take better care of patients, it makes an impact on the patients' outcomes, improves efficiency, and in the end saves health care dollars," she says.
The program started with case managers who worked only with Medicare patients and has gradually added Geisinger Health Plan's commercial population as well.
"We needed to be able to show outcomes at the initial sites and knew that because of the burden of disease among the Medicare population that we could do so with Medicare patients. The entire initiative is about driving quality. We believe that when quality is improved, cost goes down," Tomcavage says.