An array of resources helps case managers work effectively

Program reduces cost by $12.3 million in six months

By creating a series of tools and other resources, Premera Blue Cross has been able to increase the efficiency of its case management department and earn coveted accreditation from Washington, DC-based URAC.

The case management program at the Mountlake Terrace, WA, health plan is one of only two in the state of Washington to achieve URAC accreditation. The health plan covers members in Washington and Alaska.

Premera estimates that its case management program reduced its costs by about $12.3 million during the first six months of 2003. During the same period, the insurer estimates that it reduced members’ out-of-pocket expenses by $3.4 million and the amount paid out by self-insured employees whose plans are administered by Premera by $5.1 million.

"Members say our case management nurses provide comfort and security during a very difficult period. We’re also learning that these efforts to enhance quality of care and member satisfaction can lead to more cost-effective care," says Roki Chauhan, MD, Premera’s vice president for medical services and medical director for quality.

Weekly meetings to discuss troublesome cases, a case management assessment tool, a database containing appropriate goals for most diagnoses, a database of community resources, and a detailed set of policies and procedures are among the resources that case managers can use in managing their cases.

"We’ve had many new case managers join us in the last year or two, and they are really impressed about the tools we use," says Maureen Leyva, RN, CCM, case manager and team leader for the health plan’s federal employee program.

The department’s weekly case presentation meetings were named a "best practice" by URAC accreditation reviewers.

Case managers from all parts of the health plan’s coverage area participate in the weekly telephonic case presentation meetings, which are attended by at least one physician advisor, a behavioral health specialist, and a pharmacist if warranted.

Case managers may present a troublesome case on which they need advice, an ethical issue, or share information they have learned that will help other case managers.

The meetings are limited to one hour a week.

"It is my firm belief that the meetings do not go longer than an hour because they need to be managing their cases," says Mary Murray, RN, CCM, CPHQ, manager in care management with primary responsibility for the case management program.

The insurer’s 50 case managers are divided into three teams, each of which holds a separate meeting with some participants connected via telephone. The teams are organized to include members from each region’s case management staff. Case managers who want to present a case at a meeting fill out a form describing the case they want to present and the issues pertaining to it.

The form includes the diagnosis, the background on the case, the case management plan, and the issue the case manager hopes to resolve. The forms are submitted in advance so the entire team can review them before the meeting.

The form was designed to prompt the team to focus on the issue at hand rather than getting sidetracked on other patient information, and begins with the question, "What is the issue?"

"When we first started, we had the history first and the issue at the end. We revised it to keep everyone focused. You have to say up front what the issue is or it may get lost in the discussion," Murray says.

The team usually tackles between four and six cases in an hour. Some are extended from one meeting to the next with the problem solving continuing over a matter of weeks.

If there are a lot of cases, people with the most urgent issues are allowed to go first. Those who are bringing a learning experience to share may wait a week if someone has a pressing matter to discuss.

"The case manager who asks the question, Where do I go now?’ takes priority," Leyva says.

An administrative assistant on each team takes minutes, which are distributed to participants.

Case management staff attach the case meeting forms to the members’ chart to demonstrate the collaborative discussion that takes place between the case managers and medical directors. The forms are put into a manual that case managers can refer to for information to use for other cases.

"The forms and the minutes of the meeting show the flow of the case and allow us to see the processes as a whole," Murray says.

In addition to patient care and discharge problems, the case managers often discuss ethical issues that arise with their cases.

Some of the ethical issues that have been discussed include conflicts in a family over end-of-life issues and questions about why one provider refers only to a particular home health agency.

Team members often have information they believe the other case managers may find useful.

For instance, Leyva shared the information that the Society of Leukemia and Lymphoma will give $500 to cover copay, transportation, and other costs for patients with those diseases, regardless of their financial status.

The information also goes into Premera’s case management department’s extensive resource database of information on community resources for services that the plan ordinarily may not cover.

The resource database is especially helpful as case managers work with the member to find funding for procedures or tests that may not be covered under their plan.

"Each plan is purchased with benefit limitations. We work with the members to maximize the benefits they have and to identify other resources," Murray says.

When case managers begin a case, they use an assessment tool, a computerized script that helps them determine what their clients will need.

The tool covers everything from safety issues in the home to support systems, from activities of daily living to advanced directives.

"Just using the assessment tool is really helpful for new case managers. It includes triggers to make sure that everything you need is in place," Leyva says.

Over the past few years, the health plan has developed policies and procedures that ensure consistency among case managers in all coverage areas.

"I tell new case managers that if they do case management at Premera, they can do it everywhere. Our case managers are very much hands-on with their cases," Leyva says.

For instance, under the policies, case managers can’t open a case without at least verbal consent and they pursue getting written consent.

The health plan receives high ratings on its case management satisfaction survey that is sent to members after the case is closed or every six month for longer running cases.

If somebody expresses a concern, the case manager’s manager personally follows up with that person. For instance, as she prepared to close a case, one case manager left numerous messages with a family member who never passed them on to the member in case management. The patient complained in the satisfaction survey that she hadn’t wanted her case closed.

After talking to her, the case manager reopened the case and set up a better way for the case manager to contact the member.

Premera’s case management department includes a dedicated case management program for breast and lung cancer. The department has dedicated case managers for pediatrics, obstetrics, and behavioral health. The rest of the case managers are generalists who handle the rest of the cases but may fill in on a specialty case if the specialty case manager has a full caseload.

Premera case managers handle an average caseload of 35 to 40. Their contact with members depends on the acuity of the case.

Case managers generally manage the cases in their region, as long as the caseloads are manageable. For instance, if a case manager in Alaska has a maximum caseload, a case manager in Washington may take over and consult with the Alaska case manager for help with cultural issues.

Washington case managers may collaborate on community resources if they are handling a case in a different city.

When a complex case requires an on-site visit, the case manager who is closest to the patient does the visit. When a member has complex medical needs, the case manager will make a home visit. In these cases, Murray always cautions them not to put themselves into an environment where they won’t be safe.

"I’m a firm believer that a picture is worth more than a thousand words. Sometimes, we hear one thing when we talk to a member and another when we talk to a provider. A home visit gives us a chance to identify what is going on," Murray says.

For instance, Leyva made a home visit to meet with a member who has amyotrophic lateral sclerosis (ALS) and couldn’t talk on the telephone but wanted to communicate with her. His wife was on hand to help interpret what he was saying.

Time constraints are the only reason the case managers don’t do more on-site visits, Leyva adds.

At Premera, members who would benefit from case management are identified from a trigger list that includes common diagnoses. Members who are hospitalized frequently or have major trauma or a diagnosis that needs a lot of care coordination also are referred for case management.

Once a case is identified, the case managers go through an evaluation process, talking with the member and provider and conducting a health needs assessment.

The programs are strictly voluntary.

Premera gets referrals from the internal staff, providers, members, and family members, Murray says. After the case manager calls the member and physician and conducts the evaluation of the case, the Premera case manager sends an introductory letter that explains the program and the member’s rights and includes a case management consent form. The form gives the member the option to indicate that he or she does not want to be in case management.

Members receive a small brochure introducing their case manager with contact information.

"It’s just a small piece of paper that they can put on the refrigerator or in another place where it will be handy when they need it," Murray says.

The case manager works with the member and primary care physician to decide on short-term and long-term goals.

The average length of a case is about four months. Some members, such as those with ALS or multiple sclerosis, are in case management much longer.

"When the case manager believes the case can be closed, she calls the member to discuss it and lets them know they can always call back and have their case reevaluated," Murray says. "It’s hard for some members to give up the security of having a case manager who can help them answer complex health care questions. People do call us back, and we do reopen cases."