CMs work as a team with physician practice staffs
Initiative improves care, reduces costs
By embedding case managers to coordinate care for the sickest patients, Taconic Professional Resources is helping physician practices in New York state provide better patient care aligned with the Institute of Healthcare Improvement's Triple Aim initiative: better patient care and improved health for populations at a lower cost.
"Team-based care management is essential for primary care and specialty care providers in today's healthcare environment. Our case managers collaborate with the care team at physician practices to manage care for patients with the highest healthcare needs. Having an embedded case manager in the office allows physicians to focus on treating a patient's disease process or current condition," says Maria Strohmeyer, RN, MSN, CCM, director of clinical services for Taconic Professional Resources, who oversees all of the case managers within the Fishkill, NY-based organization.
The case managers also collaborate with the physician and other members of the care team to address issues that may affect successful implementation of the treatment plan, such as comorbidities or psycho-social factors, she adds. "The case managers provide educational materials or referrals to supportive resources within the patient's medical neighborhood to foster improved health. Physicians often don't have time to address these issues during a typical office visit, but they can greatly affect that patient's health outcome," she adds.
Although the case managers are employed by Taconic Professional Resources, they become part of the practice. "We provide training, placement, oversight, and the paycheck but they become part of the practice, developing a close working relationship with the patients, physicians, and the rest of the care team," she says.
Taconic case managers are RNs and have a minimum of ten years experience working in the clinical setting, as well as case management experience. They either are certified in case management or are required to obtain certification shortly after employment with Taconic. Before being assigned to a practice, they receive extensive training on how primary care offices operate, the concept of patient-centered medical homes, managing transitions of care, using their assigned practice's electronic health record, and how to manage a critically ill and chronically ill population. Taconic Professional Resources also provides ongoing support, mentoring, and training.
When the organization began its embedded case management program, the only practices that were assigned a case manager were part of Taconic Independent Practice Association, a sister organization to Taconic Professional Resources. Now, the organization is providing case managers for 74 practices in the Capital District-Hudson Valley area under a four-year grant from the Centers for Medicare & Medicaid Services' Comprehensive Primary Care Initiative. The organization provides training and education to the practices as they transform into patient-centered medical homes. "We are working with the 74 practices to achieve milestones that will transform primary care providers to be more in line with the future of healthcare. All of these practices function with the patient as the center of the team and with coordinated care provided within a primary care office," she says.
Some of the case managers are embedded in multiphysician practices. Others work in solo practices.
"The biggest challenge the embedded case managers face is assisting the practice in transforming the current workflow to accommodate a new model of care. Once this is accomplished, the physicians and staff in the practices see that embedded case managers add value," Strohmeyer says.
The embedded case managers focus on the patients at highest risk, those considered critically or chronically ill with multiple comorbidities and who require support in following their treatment plan and managing their conditions, as well as patients going through transitions in care. In most cases, these patients represent 20% of the practice's entire patient population.
Patients with the higher risk scores are referred to case management. These typically include patients with diabetes, coronary artery disease, heart failure, chronic obstructive pulmonary disease, or cancer, as well as patients who have chronic conditions with psycho-social components. Some patients have stable medical conditions but with psycho-social conditions that increase their risk score temporarily. For instance, a patient may not be able to afford his medication, lives alone with no family support, or recently experienced a sudden change in health status.
In addition, any patient who is being admitted to or discharged from a hospital to a skilled nursing facility or who is going home with significant needs is referred to case management. In the case of hospitalized patients, the case managers follow up by telephone once the patients are discharged to find out how they are doing. They review the treatment plan, perform medication reconciliation and ensure that patients have a follow-up appointment with their primary care physician.
When patients are referred to the case managers, they perform a comprehensive assessment, either by telephone, or in person if the patient is referred during an office visit. The assessment determines what patients know about their conditions and treatment plan. It includes information on the patients' living situation, nutritional status, family or caregiver support, financial issues, and any barriers to care. Using motivational interviewing, the case managers find out the patients' goals and concerns. Once they complete the assessment, they coordinate with the physician and other care team members to come up with a care plan that supports the treatment plan's overall goals.
"We want patients to take ownership of their own care by collaborating with the case managers and the care team on agreed-upon goals for improved health," she says.
The case managers monitor the patients by telephone as well as in person. When patients come into the office, the case managers may meet with them before or after the visit with their provider. If patients need more follow-up, they call them at regular intervals to answer questions and find out how they are managing their condition and if they are having any issues that need attention. "The goal is to prevent visits to the emergency department and hospital admissions by getting patients back into the office before their conditions spiral out of control," Strohmeyer says.
The case managers and patients review the care plan at each visit or during each telephone call. If certain things aren't working as expected, the case manager and care team can tweak the plan. "The plan is constantly being evaluated, and updates are implemented as needed," Strohmeyer says.
When the goals are met, the patient may be discharged from case management or placed on a maintenance plan where the case manager follows up at less frequent intervals to help the patient maintain stable health.
How the case management program works varies among the practices. "The collaboration between the case manager and the care team can be very formal or informal, depending on the workflow implemented in each practice," Strohmeyer says. Some practices have formalized patient-centered medical home meetings during which the team presents cases and collaborates on the issues that need to be addressed and how they might improve coordinated care for a patient. Some case managers and team members collaborate in the hallway between office visits or at the end of the day.
"The most important thing is to keep communication open between members of the care team and the case managers. The case managers work continuously to become part of the care team so they are not seen as an outside entity," she says.