Social intervention prevents crisis for elderly

Hospital admissions drop 50%

ElderMed America in Woodland Hills, CA, knows that psychosocial interventions improve quality of life while reducing health care costs for capitated Medicare patients. Its care coordination project cut hospital admissions by 50% for 93 capitated Medicare patients considered "at risk."

Patients in the care coordination project significantly reduced their reliance on the acute care setting, says Gayle Whitcomb, MSW, MSG, senior consultant with ElderMed, who with the help of an assistant managed and directed service for the care coordination project 20 hours a week from April 1995 to April 1996. Results of the care coordination project include:

• Total hospital admissions dropped from 22 during the 12 months before the project began to 11 during the 12 months of the project.

• Total emergency department visits dropped from six during the 12 months before the project to none during the project.

Physicians referred patients to the program for a variety of reasons, including:

• difficulties with activities of daily living (ADLs);

• transportation problems;

• suspected elder abuse;

• difficulties with medication compliance;

• caregiver stress or burnout.

"Over 50% of the patients in the program had a primary caregiver. Many of those caregivers were elderly spouses. We not only looked at the ability of patients to perform ADLs, but [at the ability] of the caregiver, as well," Whitcomb says. In addition, many older caregivers become easily confused about proper medication use, she says. "We routinely assessed whether the caregiver was able to provide appropriate care and administer medications properly."

The value of office visits

As physicians referred patients to the care coordination project, Whitcomb began by reviewing each patient’s medical record at the physician’s office. "Going to the office to review records was also a good opportunity for me to promote the program to the physicians’ office staff. While I was there, I would explain the types of patients we were looking for and ask if staff members were aware of patients who might benefit from the program," she says.

Her other marketing efforts included a formal presentation to the medical group physicians and a flyer identifying the types of patients appropriate for the project, which was distributed to physicians and their staffs as well as to home health agency staff and hospital discharge planners.

Whitcomb also asked patients in the project to complete a self-assessment of health status and included the results as part of the patient profile. The health status questionnaire produced several important findings, she notes.

For example, in every category, from general health and perception of pain to physical functioning, patients assessed themselves lower than the average scores for the general population of adults over age 65. In addition, 53% of patients were found to be at risk for depression, and care coordination interventions were selected to address that psychosocial risk, Whitcomb says. (For further discussion on the risk assessment and treatment of depression, see story, p. 73.)

After reviewing the medical record, Whitcomb would call the patient on the phone and then, in many cases, provide an in-home assessment of psychosocial needs. "Our primary goal was to prevent inappropriate use of medical services. To do that, we concentrated on providing [for] unskilled needs that often fall through the cracks but that can lead to medical crisis," she says. Some of those services included:

• transportation to medical appointments;

• home-delivered meals;

• timely information about prescriptions and over-the-counter medications;

• homemaker/personal aides;

• respite care for caregivers;

• behavioral medicine counseling services.

Perhaps the most important service the care coordination project provided was to keep open the lines of communication between providers.

"When patients were admitted into home health or the hospital, I would contact the nurse or discharge planner and explain the services that were already in place. I would also tell them what I could about the patient and the family," Whitcomb says. "When patients were discharged from the hospital or home health agency, I again contacted the nurse or discharge planner to ask about the discharge instructions."

Whitcomb then would make sure patients and caregivers understood the discharge instructions and follow up to make sure those instructions were followed. "Communicating with the hospital discharge planner also gave me new information when I went to the home to follow up on patients," she says. "I was well-prepared for any changes in the patient’s status, and I knew what services had been arranged."

Helping patients, families communicate

During home visits, Whitcomb also coached patients and family members on how to communicate better with their physicians and other providers. "For example, if the patient seemed confused about medication use, I would tell the patient we were going to practice asking the doctor about their medications. Then I would help them put all their medications in a bag to take with them on their next office visit," she explains. "I would also prepare a report for the doctor to give them some advance notice that the patient was coming in with specific questions about their prescriptions."

The care coordination project focused on empowering patients and caregivers by teaching them how to access community services and care for themselves, rather than always doing it for them, Whitcomb adds. "There was a patient who had trouble with transportation. I connected her with a community transport company, but she was very anxious about making the first call. Instead of calling the company for her to arrange the service, I coached her through the call. I told her what questions would be asked. Then, I stood next to her while she made the first call and helped her through it."

Care coordination is an age-old concept for case managers, but it is vital to the success of capitated Medicare programs, whose elderly members are traditionally high users of medical services. Some valuable lessons Whitcomb learned during the 12-month pilot project include:

• Involve the family and encourage caregiver input in assessment and plan development.

• Assess the skill level of the caregiver.

• Design a coordination plan that enhances the patient’s medical care.

• Clarify what the patient and caregiver perceive as needs to be sure there are no differences in priorities.

• Provide the patient with a copy of the coordination plan and a list of goals and tasks for both caregiver and patient.

• Focus on a few goals at a time to avoid raising patient anxiety.

• Teach patients and family members how to use information to make their own health care decisions and arrange their own services in the future.

• Encourage patients and family members to initiate phone calls and contact the care coordinator.

"There were patients we had discharged from the care coordination project that were readmitted because there was a change in the patient’s status, and either the patient or the family member contacted us. The patient or the family member actually opened up the case again, but we were able to step back in and coordinate services that helped prevent a medical crisis," Whitcomb says.

Satisfaction equals retention

Not only did patients in the project have fewer physician visits, hospital admissions, and emergency room visits, but they reported a high degree of satisfaction with care coordination services. "Member satisfaction is closely linked to member retention in the competitive Medicare health maintenance organization market," stresses Whitcomb. A total of 89 surveys were mailed to 45 patients and 44 family members served by the project, followed a week later by a reminder postcard. The response rate was 65%. Satisfaction survey results include:

• 91% rated the overall quality of services "very good" or "excellent."

• 81% rated the communication among the social worker, physicians, nurses, and community agencies "very good" or "excellent."

• 98% "strongly agreed" or "agreed" that the social worker made a difference in the care they received.

Whitcomb also surveyed providers who referred patients to the project. Among those surveyed were physicians, physicians’ office staffs, the medical groups’ case managers, behavioral health counselors, and home health agency staff. A total of 24 surveys were sent to providers with a response rate of 75%. Results include:

• 89% "strongly agreed" or "agreed" that having a social work intervention available saved the provider time.

• 100% "strongly agreed" or "agreed" that providers received timely information about patients referred to the social worker.

• 100% "strongly agreed" or "agreed" that having a social worker available helped prevent patient problems from leading to a crisis.