CMs, social workers collaborate for better care

Indigent learn to navigate the health care system

A multidisciplinary program staffed by nurse practitioner case managers and social workers has resulted in dramatic decreases in admissions, lengths of stay, and emergency department visits among indigent patients cared for at the University of Iowa Hospitals and Clinics in Iowa City.

In the first five years of the Care Management Program at the University of Iowa (CMPUI), adjusted total charges for acute admissions dropped by more than $7 million, while the number of people eligible for care increased.

"It’s a very challenging population. They have medical needs as well as social and educational issues. All of these add to their medical problems and complicate their situation. We recognized early on that to be able to better care for the patients, we’d have to address their psychosocial needs as well as their medical issues," explains Cynthia Doyle, MSN, CS, ARNP, Cm, team leader and nurse practitioner case manager of the CMPUI.

The nurse practitioners do not provide direct, hands-on medical care. Instead, they act as case managers and, because they are nurse practitioners, they can make decisions on appropriate care and medication.

"We can collaborate with the primary care pro-viders and tell them a medication isn’t working and make a suggestion for changing it. We work with them, and they work with us," Doyle says.

The social workers comanage complex patients, help with communication between patients and providers, and help the patients access community resources, mental health and substance abuse care, and assist them in signing up for other entitlement programs such as disability or social security if they meet the medical requirements.

"Our goal is to ensure that the health care our patients receive is comprehensive, high-quality, and cost-effective, and to get them back on their feet," Doyle says.

The program is sort of a last resort for indigent Iowans who do not qualify for Medicaid, Medicare, or other entitlements. Those who are eligible get a "state paper" that allows them to get medical care at the University of Iowa.

One of the first items on the to-do list when the program was begun was to establish the majority of patients in a primary care clinic, cutting down on the use of special services, Doyle says.

Now, the nurse practitioners authorize and review all special care. In many cases, going to a specialist isn’t necessary. For instance, a diabetic with cardiac disease and a dermatological problem could go to three different clinics, but in many cases, a good primary care physician would be able to treat all of the patient’s illnesses.

When the care manager program was instituted, the hospital set up an authorization system so that the patients can’t self-schedule in any specialty clinic without the nurse practitioner’s approval. The primary care provider is in charge of the patient care. The nurse practitioners collaborate with the physicians and provide information on the patient’s background, conditions, and issues that may prevent them from following the treatment plan.

"We do a lot of triage," she says. If a patient who has a state paper for indigent care is admitted to the hospital for any reason, a nurse practitioner visits him or her in the hospital and helps with coordination of care.

"We have been able to significantly reduce the length of stay for this population," Doyle says.

The nurse practitioners collaborate with the unit team — physicians, nurses, anyone else involved in the care — making sure that whatever medical treatment plan is developed moves along in a timely fashion.

"We make sure that the plan is followed beginning at the time of admission so the patient moves through the system in a more efficient manner," Doyle says.

For example, if a physician has ordered an electrocardiogram, the nurse practitioner case managers make sure it’s done in a timely fashion so the patient’s discharge isn’t delayed because the test hasn’t been completed.

The program includes a 24-hour triage mechanism for patients. On weekends and after hours, a nurse is on call who is contacted if the patient needs care. Often, the nurse practitioners can intervene to prevent an admission or an emergency department visit.

The telephones are answered by two RNs who field 100 to 150 calls a day from 8 a.m. to 4 p.m. Most are from patients who need medication, want to report symptoms, or have psychosocial issues.

Before the CMPUI was begun, there was no one to help the patients get to the appropriate venues for care. The patients were overusing the hospital’s appropriations for indigent care by millions of dollars a year, Doyle says.

"They were their own case manager and had to negotiate the system without any assistance. We consider ourselves as captain of the ship. We make sure the patients get what they need," she adds. "They would come here to get care and go from one specialty to another specialty."

Many times, the specialty clinics didn’t communicate with each other or the communication was slow, an occurrence Doyle says is typical of large academic medical centers.

"They would go to one clinic and get a prescription and go to another clinic and get another set of medications, and no one was overseeing it," she says.