Case study shows creative solutions under capitation
Case study shows creative solutions under capitation
Successful outcomes at 69% of usual cost
Today, J.P. volunteers at his church and participates actively in parenting his children.
But less than a year ago, J.P. required expensive round-the-clock care, and his wife lived in fear of the violent outbursts that resulted from J.P.’s struggle to recover from a massive head injury.
By using a creative approach to deal with his problems, the brain injury team at HEALTHSOUTH Tri-State Rehabilitation Hospital in Evansville, IN, drastically reduced the cost of treatment for J. P. when more traditional approaches had failed.
Under a capitated contract, the team successfully treated J.P. at a rate that was 31% less than their average daily charges.
Here is how they did it:
J.P., a 29-year-old male, was admitted as an acute rehabilitation inpatient on HEALTHSOUTH Tri-State Rehabilitation Hospital’s brain injury unit on Feb. 1, 1995, almost a year after sustaining a skull fracture in an accident at work.
Complications of the injury included atrophy of his right optic nerve, keratitis of the left eye, cranial nerve damage, temporal mandibular problems, and depression. When admitted to a rehab unit in his home town, he was considered to be on a Level II to Level III on the Rancho Los Amigos scale.
When discharged from that rehab unit in July 1994, he was to receive home health services and participate in a day rehab program (not at Tri-State). After two days, the patient refused to continue with the day program and required 24-hour-a-day attendant care at home, according to his wife.
J.P. continued with home health but developed severe agitation and behavioral problems, including threats of suicide and violent behavior toward his wife and children. During one outburst he attacked an ambulance attendant and tried to jump out of a moving vehicle. Because his behavior frightened his family, his wife had him admitted on an emergency basis to a psychiatric facility.
He was referred to Tri-State by a catastrophic case management company hired by his insurance provider to manage the case.
Psychosocial needs
At Tri-State, the patient started out on a secured brain injury unit in acute rehab where the staff did an evaluation and assessment on his behavioral outbursts.
The team initially concentrated on the psychosocial needs of the patient and the family. They taught parenting skills and coping mechanisms the patient and his wife needed to deal with J.P.’s triggers in a constructive manner.
As soon as the patient was fairly functional in activities of daily living, the team cut back on occupational therapy services in favor of more psychosocial services for the behavioral outbursts.
Before capitation, the patient routinely had physical therapy, occupational therapy, and speech therapy twice a day, says Joe Lukac, MRC, CRC, director of case management.
Although J.P. had a history of outbursts, he had no such episodes in the structured environment of the hospital.
"We had to teach him to recognize what triggered his outbursts and to cope with them on his own. To do this we had to find some way to remove the structure and maintain supervision while gradually adding family members," says Debbie Proctor, BSRN, CCM, program leader/case manager of the brain injury team.
The patient was moved to an independent living center apartment on campus with supervision. The outbursts still weren’t triggered so they added the wife in.
"All the time, we had them keep a diary of any outbursts and discuss them with the psychology staff. The wife kept one, and the patient kept one. In the beginning, the patient had to keep a verbal diary because he couldn’t write," Proctor says.
The couple attended individual and joint sessions with a psychologist to discuss their feelings and emotions.
Adding the children
When no major outbursts occurred, the rehab team added the children one at a time. The patient was feeling some stress by the time all three children moved into the independent living apartment but did not experience any outbursts like before.
At this point, J.P. began to attend community re-entry services half a day. "We transitioned him more and more into a community-based setting to address his rehabilitation needs and his behavioral needs," Proctor says.
After that, the family was moved to an apartment off-campus. The wife transported him to CRS and back each day. The patient had to have home health services at night for the eye drops he had to use.
Before treatment at Tri-State, the patient had to have 24-hour-a-day, seven-day-a-week attendant care, partly because of the wife’s fear of his outbursts.
"We were able to show her that he was capable of performing some parenting skills that helped," Proctor says.
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