NICU case management pays off for health plan

Program cuts average of four days off length of stay

A case management program dedicated to infants in the neonatal intensive care unit (NICU) has saved Blue Shield of California an average of four days length of stay off each NICU admission, saving the health plan about $3,500 a day.

"We have been very successful with this program. Our success is due to a combination of things from my perspective," says Kathy Hoksbergen, RN, MHA, director of medical management operations. "We promote early parent education so parents will feel comfortable taking their baby home from the hospital. If we don’t start educating parents until the doctor says the baby is ready to go home, the discharge will be delayed."

The health plan, based in San Francisco, started its neonatal case management program two years ago when it discovered that monthly case reports consistently showed that about half of the plan’s catastrophic patients were premature infants.

At the time, the health plan had a case manager with a specialty in neonatal intensive care management but not a neonatologist on the staff and contracted with a vendor specializing in NICU case management, Hoksbergen says.

The plan initially assigned a nurse with an NICU background to work as a liaison with the vendor.

Cost-effective management

Within about a year, the staff at Blue Shield of California determined that having a vendor manage the infants was not the most cost effective way to manage the infants’ care.

"We determined that we could perform the same functions as the vendor and do them more efficiently and cost effectively," Hoksbergen says.

In the beginning, the plan referred all infants who weighed less than 1,500 g to the vendor and managed the others internally by telephone. Eventually, the Blue Shield case management department handled the care of all of the low birth weight and premature infants.

"Working with the vendor, we were able to build our knowledge and resources internally. We can get just as good results without the cost of the vendor when we handle the cases ourselves," Hoksbergen adds.

Now the program has a dedicated case manager who specializes in handling infants in the neonatal intensive care unit and a board-certified neonatologist. She is supported by two other nurse case managers with experience in handling babies in the NICU, adds Paula Ackerman, RN, BSN, CCM, supervisor of case management.

Blue Shield of California is notified by the area hospitals when there is an NICU admission. The neonatal care manager assesses all infants, making an estimated length of stay based on the gestational age at birth or the mother’s estimated date of delivery.

If the baby meets the criteria for NICU case management, a Blue Shield case manager handles the care.

Whenever possible, the health plan facilitates the infant’s admission to a tertiary center adept at handling premature infants.

"We try to get the baby channeled to a facility that can specialize in its needs. Our case manager works closely with utilization review and discharge planning departments at the facility and works to line up community services when they are needed," Ackerman says.

Discharge planning

The goal of the program is to start discharge planning early and to educate the parents as soon as possible so they’ll be prepared to take the infant home as soon as it is appropriate, Hoksbergen says.

Typically, active discharge planning begins when the baby reaches a corrected gestational age of 34 weeks. The corrected gestational age of the baby is based on a 40-week gestational period during pregnancy. A baby born early at 30 weeks gestational age would have a corrected gestational age of 34 weeks four weeks later.

The case manager works with the physicians, parents, home health, and durable medical equipment providers to develop a working care plan to address the infant’s needs and follows up regularly during the hospital stay by making biweekly utilization reviews and following up with the parents and home care providers after discharge.

"Some babies require very complex care after discharge. In those cases, the NICU case manager works with the parents and the provider to create an appropriate care plan," Ackerman says.

For instance, if the baby will need home health, the case manager facilitates finding a home care agency that can handle the infant’s special needs and makes sure a referral is in place on the day of discharge.

One of the biggest difficulties is finding a home care agency that specializes in the care of infants with complex needs, Ackerman points out.

The care manager works with the family to identify preferred home health and durable medical equipment providers in the family’s area who can take care of the baby’s needs.

If the family lives in a rural area, it’s extremely important for the parents to be trained in CPR, use of feeding tubes, and whatever else it will take to care for the infant, Ackerman says. Due to limited resources in their community, the parents need to be able to rely on their ability to care for the infant until more highly trained support is available, she adds.

The care manager follows up with the facility’s social worker and discharge planner to make sure the baby is referred to community and state resources such as public health nursing or California Children’s Services if appropriate, based on the infant’s diagnosis, developmental disabilities, and financial need.

The plan has on-site patient care coordinators who work in high-cost, high-volume facilities throughout the state. The on-site case managers handle all catastrophic patients who are in the acute level of care. They coordinate with the neonatal specialist on the care of infants in the NICU.

The on-site case manager is primarily responsible for on-site review and gets the NICU case manager the information needed for discharge planning.

"The on-site nurse is focused on the hospital stay. The NICU case manager is focused on the entire continuum of care," Ackerman says.

The NICU case manager communicates with the family while the infant is in the hospital and after discharge.

The care manager works with preferred home health agencies to follow up in the home for continued patient education and home safety evaluation. In cases where a contracted home health agency is not located, the care manager has the ability to negotiate with a noncontracted home health agency able to provide the care.

The case is open for case management until the infant’s goals have been met. In some cases, the NICU case manager still is working with the infant’s parents a year after discharge. In other cases, she may close the file after 90 days. The time a baby remains in case management depends on the severity of illness and the amount of care that is required to complete the goals set between the care manager, parents, and care team.

"The case manager helps familiarize the family with community resources that can provide services which may not be covered by the plan or in the event a particular plan benefit is exhausted," Ackerman says.