Discharge Planning Advisor: Care program incorporates office-based CM approach 

Initiative expands as physicians learn its purpose

Physicians aligned with Sutter Health in Sacramento, CA, are giving glowing reviews to a care coordination program they once failed to recognize, pleased that it is meeting myriad patients’ needs and saving office time in the bargain.

What began as a trial medical office case management program — featured two years ago in Discharge Planning Advisor — has evolved and expanded and been absorbed back into the Sutter Care Coordination Program, explains Jan Van der Mei, RN, care management director.

"Physicians are delighted with the program and find that it is very valuable to them," she says, noting that in addition to addressing patients’ psychosocial needs, the program assists patients with obtaining transportation and applying for discounted or free prescription medications through various drug company programs.

Physicians surveyed about the program report "extreme satisfaction," Van der Mei adds.

What is ironic about the situation, she points out, is that earlier physician response to the care coordination program was less than enthusiastic, even though it offered the same benefits now being provided.

When that program — a centralized nurse/ social work model — expanded in 1997, "we found our own patients," Van der Mei says, drawing from emergency department (ED) patients and those who were admitted to the hospital more than two times in six weeks and through health risk screenings of new members of the Sutter managed care organization.

"We connected with the physicians, told them what we were doing, but got very few referrals," she says. "[Physicians] thought we were gatekeepers and were suspicious of us. Now they truly understand what case management is."

In 2001, the medical director of the Sutter Physician Alliance (SPA) approached Van der Mei with the idea of putting nurse case managers in the physician office setting, she notes. "He was looking for opportunities to provide a value-added service for SPA physicians and felt this was one way to accomplish that goal."

After meeting with physicians, who gave examples of the kind of assistance and support they were looking for, Van der Mei began to put the program together. "I felt this was a natural progression of Sutter Care Coordination."

Three registered nurse full-time equivalents (FTEs) were added to her budget, which already supported four RNs in the centrally located care coordination program.

Nurse case managers were based in "care centers," each of which house a group of between eight and 10 physicians in the Sutter Medical Group, Van der Mei adds, with each RN assigned between 12 and 15 physicians. "Although space is always an issue, we were able to find space."

Independent practice association (IPA) physicians who were exclusively linked with Sutter also were included in the program, she notes, but not those who have contracts and allegiances with other systems and payers.

Sutter didn’t want to get involved in treating patients who were members of other managed care plans, Van der Mei adds.

"With the original care coordination program," she explains, "the impetus of it was us taking on full risk, so the bulk of the patients in that program were managed care. When we move into the physician offices, we have to take all their patients, not just managed care patients."

"If we’re working with physicians who are exclusively with Sutter, we even work with their MediCal and other patients," Van der Mei says.

Now the program is about 60% managed care, she adds, "but we still meet our return on investment." Sutter physicians and hospitals have more than enough patients to keep them busy, Van der Mei notes, "and don’t really want patients who are more appropriately treated elsewhere to be in the hospital."

Saving time, meeting needs

Two RN case managers were dedicated to the IPA, she continues. "They each have a few physicians in the medical group, as well as the IPA physicians, and work from their office at the care center. They do go to the IPA physicians’ offices to see patients — generally during a scheduled appointment — and make rounds if a patient is in the hospital.

"We tried having staff stay at the IPA offices, but they were in the way — these are independent offices, and there was no [extra] space whatsoever," Van der Mei adds.

Nurse case managers working in the central areas of the care centers, however, found they could do some effective intervening when they overheard medical office assistants telling patients who called in with problems that they should go to the ED, she notes.

"The case manager was able to say, Do you want me to talk to the patient?’ and could divert a lot of them," Van der Mei adds. "The physicians didn’t want patients turned away, sent to the ED, but the medical assistant wanted to tell [the patient] something and didn’t have room on the schedule."

Having case managers handle patients — in many cases without having them go to the ED or come to the office — has made physicians happy, she points out. "Patients who were calling the physician every week are now calling the case manager."

Two of the original nurses with the office case management program found it "wasn’t a good fit for them," Van der Mei says, in part because they tired of having to convince physicians of the program’s value. After they quit and she was hiring two new RNs, she adds, "I realized I really needed to hire them into the care coordination program and incorporate all of the office case management into that."

"[The office case managers] needed the support of the social workers and the health care coordinators who do the ongoing monitoring," Van der Mei says.

"So while we started out saying that office nurse case management was a separate program, it really became part of care coordination," she explains.

Now each social worker and health care coordinator is designated to work with two nurses, she adds, and, in turn, with the physicians to whom those nurses are assigned.

"So there are really teams," Van der Mei says. "The physicians not only have nurses but social workers. When a nurse is out there and gets a psychosocial case, it goes directly to the social worker, and the physician is aware of that. The social worker then discusses things with the physician."

While it took physicians a little while to understand that the nurses were part of a larger team that included staff located elsewhere, the care coordination program now gets between 175 and 190 physician referrals a month, she notes. "We used to get maybe 10 a month."

After the first-year physician satisfaction survey brought positive results, the decision was made to expand the program from Sacramento to the Roseville, CA, area, Van der Mei says. It now serves about 2,000 patients, compared to some 1,200 when the nurses first moved into office case management, she adds, while the original care coordination program served about 900 patients.

Patient satisfaction surveys also have been very positive, she adds, although there was some initial confusion because patients didn’t connect the nurse who was helping them with the care coordination program. "They really think the case manager in the office works for the physician," she adds. "So we’ve started putting the nurse’s name on the survey."

SCCP staff now have the ability to create a daily report identifying all patients in the program who have been admitted to the hospital, Van der Mei notes. "We also identify patients who are in one of the Sutter managed care plans but not in our program who might be appropriate for follow-up."

This capability also allows her staff to follow up with their patients who are admitted to make sure their discharge plan is adequate and that they have any new medications that might have been prescribed, she says.

While the care coordination program originally had an independent database, in March 2003, it was added to the electronic medical record model used by Sutter’s medical group, Van der Mei explains. As a result, physicians now have access to "a summary of everything we’re doing."

"That’s been great," she says. "It linked us very closely to them. The IPA is not on the electronic medical record [EMR], though, so we always need to have a paper process for communication as well as the EMR."

A current focus for the care coordination program is end-of-life, advance care planning for patients, Van der Mei notes, and her staff recently went through four days of training and planning on how to assist physicians in this area.

Advance care planning, she points out, is one of the outcomes measured for certification of Sutter’s disease-specific programs by the Joint Commission on Accreditation of Healthcare Organizations.

"Our goal is that patients will have at least the beginning of this discussion within 90 days of entering the program," Van der Mei says. "[Lack of such information] is one of the problems on the care plan for each patient. It’s important for everyone to do this so our loved ones know what we want."

[For more information, contact:

  • Jan Van der Mei, RN, Care Management Director, Sutter Health, Sacramento, CA. Phone: (916) 854-6896. E-mail: vanderj@sutterhealth.org.]