Transition to continuum of care ends in success
Part One of a Two-Part Series
Transition to continuum of care ends in success
Group manages health in community
When Salt Lake City-based Intermountain Health Care (IHC) opened its doors 25 years ago, the 15-member hospital group was in the infancy of developing a continuum of care that ultimately would manage patients effectively and save money for employers, hospitals, and clients.
It all started in the 1970s, when the hospital company began building a care management system that focused on the episode of care. By the 1980s, the system was building a continuum and a team to manage the continuum. And although Intermountain was caring for acute care patients adequately, it took until the 1990s for the company to realize it could better manage people with chronic illness, says Jill Hoggard-Green, RN, PhD, assistant vice president of clinical support services for IHC.
Since 1996, IHC has taken extra steps to extend its reach and has begun tackling health issues outside its facility via a successful work-site partnership with a local firm.
The nonprofit charitable health care organization today is made up of 21 hospitals, several clinics, and about 400 physician practices, and it serves roughly 500,000 clients under its insurance plan.
"You can’t manage care unless you’ve built an integrated continuum of services, and you are constantly refining them," says Hoggard-Green. "All of us want to improve the health of the population. But I don’t believe there is one of us who thinks that if you do exquisite care management in a hospital or exquisite care management in a physician’s office that you alone will make a substantial difference in the health of the population. All of us know we’ve got to extend our reach."
IHC began developing a continuum by building its own transitional care units, hospital-based nursing homes, rehabilitation centers, and home health agencies.
"Although we were building a continuum of services, we still didn’t have all of the mechanisms available to manage patients effectively," Hoggard-Green says. So in 1988, the group chose the case management route and began experimenting with different models.
Ultimately, IHC selected a nurse-social work team model because it provided a good support structure for employees actually implementing the care. Case managers are integrated with the quality utilization manager and are fiscally accountable for the care given to a patient or patient population. The hospital benefited from the case managers through a reduced cost of care.
At the same time care management was going on, so was insurance case management. The group thought IHC could extend its ability to care for patients through a clinical integration concept. Under clinical integration, IHC worked to improve the health of interdisciplinary teams or populations of people who were well or were acutely, latently, chronically, or terminally ill.
"We wanted to design strategies around each one of them. We kind of stacked the deck," Hoggard-Green says. "We had analysts and quality managers to partner with the doctors, the nurses, the social workers, and the therapists. We are going to do this systemwide because we think interdisciplinary care — where you are focusing on algorithms and using outcomes to improve your practice — is fundamentally what we need to do to improve care."
And that’s when IHC determined it was doing well with people who were acutely ill and had an opportunity to help people stay healthy and to improve the health of chronically ill patients.
"We weren’t focusing extensive efforts on the people who were well — people who never walk into a physician’s office or hospital," she says. "Thirty percent to 40% of the population does not seek health care. We have a whole lot of people who are paying for insurance and not seeking anything — and we are not effectively helping them stay well."
Properly managing the chronically ill will continue to become a more important issue as the baby boomers grow older. By 2020, more than 30% of the population is going to be over 65, Hoggard-Green says. Most people get their first chronic illness in their 40s and 50s, and by the time they are 65, most have two chronic illnesses. "Our health system needs to be designed for us," she says.
Using a proactive approach, IHC elected to take care management to the people. Several vehicles exist for this approach, including schools, work sites, primary care facilities, and the Internet.
"Stop reacting, find any point where you can assess the health of the population voluntarily, and then provide care management," Hoggard-Green recommends. "Care management consists of education and coaching, and it makes a profound difference."
Partnering with business
IHC has had particular success with work-site partnerships, especially with one Salt Lake City-based firm.
The company, which employs about 1,000 workers, approached IHC five years ago looking for help in improving the health of its employees.
The unemployment rate in the surrounding area was low, and the company had a low turnover rate, with an average employee age of 40. "They saw productivity as a major issue, and they wanted a healthy work force," Hoggard-Green says.
IHC and the company formed a partnership based on protection of employee confidentiality and voluntary participation on the employee’s part.
IHC was given clinic space at the work site, and employees were given paid time off to participate in IHC’s health classes. Employees were given a 32-question health assessment so health care workers could design a program around certain behaviors.
"We offered a lot of services at that site. We’ve got a nurse care manager, a physical therapist, self-care books, and health promotion activities. The first year, IHC paid for the nurse case manager, but the second year, the company was so impressed that it offered to pay the salary of the nurse case manager."
In four years, program participation increased from one-third of the employees to almost 100%. Several factors drove participation, including a couple of employees who were having a difficult time working shifts and managing their health conditions. "At their request, we were able to help them better manage their care," Hoggard-Green says. "Then, those employees talked a lot to their colleagues about the program."
It’s free, it’s confidential; why not use it?
Not only did word of mouth help; the employees started to trust IHC because the system had kept its word about confidentiality. "Also, working with the care manager was free, so most of them started thinking, why not,’" she says.
The work-site care manager, an IHC employee, deals with patients in the work-site clinic as well as in patients’ homes, the primary care setting, or any place the patient would like to meet. The care manager is responsible for assessments, education, coaching, and coordination of care. She also is fiscally as well as clinically accountable for the care of the patient.
Hoggard-Green says the work-site care manager was responsible for the success of many health populations driven by assessments and clinics.
"The care manager identified several people in their 30s to 50s who had major health problems," Hoggard-Green says. "People with glucoses over 500. Folks who have asthma who are in the red zone all the time."
According to the employees, the program made a difference in the way they feel.
"There was overwhelming support at all levels of organization. There was not one respondent who says the program should be discontinued," Hoggard-Green says. "They say the value was that it helped them improve their health; they saw it as a health intervention. Second, they thought they had better access to services and it was more convenient."
The program also provided better education and awareness, which led to attitude and behavior change. Not only that, the company gained tremendously as employees viewed it as an investment in them. "Our unemployment rate is around 3%, so we are really in a tight labor market," Hoggard-Green notes. "Keeping people happy is important."
Regarding the cost, Hoggard-Green says a cost-benefit analysis determined that the program was cost-neutral. "So the way I look at it is, we can fundamentally improve health at no cost."
Next month: Part II — Measuring the effectiveness of continuum of care management.
For more information, contact Jill Hoggard-Green, RN, PhD, assistant vice president of clinical support services, Intermountain Health Care, Salt Lake City. Telephone: (801) 442-2000.
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