Auto phone systems confuse frail elderly
Auto phone systems confuse frail elderly
Program offers a better way to communicate
A frail elderly man calls an advice line with a medical question. He is breathless and panicky. He hears a message that informs him to press "2" on his touch tone phone for one service and "3" for another. He’s hands are shaking, so he hits the wrong numbers. In his frustration, instead of making an appointment with his health clinic, he goes to the emergency department for treatment.
Medical systems and health plans often use automated communications systems to direct plan members to the appropriate department. But such systems often are confusing for the frail elderly. Many times they give up, and their medical conditions such as heart disease, asthma, and diabetes worsen due to lack of proper medical attention.
The California Division of Kaiser Permanente in Walnut Creek implemented the Access, Comprehensive Care and Education Program (ACE) in June 1996 to get frail elderly the help they need in a more user-friendly manner. ACE uses a multidisciplinary case management approach to coordinate the care of frail elderly members, and eliminate barriers that discourage them from seeking care, explains Sandra Brown-Robinson, program manager for ACE.
The program targets members who have had a high number of emergency visits, hospital stays, and clinic care in the past year. "We’re trying to identify our most frail members and provide quick and easy access to us," says Dale Grahn, MD, a geriatrician who heads the ACE team. ACE provides office visits, a toll-free telephone number staffed around the clock, and home visits. The services are aimed at providing more intensive care to prevent medical crises and reduce unnecessary hospitalization and emergency visits.
To participate in ACE, Kaiser members must meet the following criteria:
• Member has been seen by 12 or more providers in primary care in the last 12 months.
• Member has had six or more emergency visits.
• Member has had four emergency visits and two hospitalizations.
• Member is over age 50.
• Member has approval of his or her primary care physician.
Assessment includes safety, medications
At enrollment, a social worker or nurse case manager conducts an in-home assessment of new members. "We look at a variety of health and social issues," says Brown-Robinson. "We include a home safety check and a complete psychosocial history. In addition, if they haven’t made any end-of-life decisions, we leave them written materials to read over."
The assessment also includes a complete cataloging of the members’ medications. "The social worker or nurse makes a complete medication review and brings that information back to ACE for a team meeting. A mini mental exam and depression scale are also part of the assessment, if appropriate."
The in-home assessment is followed by the patient’s first office visit. Information gathered during the home assessment and office visit is shared with the entire ACE team. "If the patient is too difficult to move, the nurse practitioner makes a home visit with the case manager," says Brown-Robinson.
The team includes Grahn, two nurse practitioners, a nurse and a social worker who share case management duties, and a medical assistant. The entire team sits down and develops a care plan together.
"We use a self-directed team concept," says Brown-Robinson. "Everyone, including the ACE secretary, has some working knowledge of each patient in the program. It’s one of the pluses. When a member calls in, there’s always someone who knows who they are and what their situation is and can direct them to the appropriate care."
Phone calls to ACE’s toll-free number are answered after no more than four rings 95% of the time. During the day, calls are answered by an ACE staff member who knows the patient. After hours, a specially trained nurse with quick access to the ACE physician answers the phone.
An ounce of prevention
Results are promising. There are 151 patients currently enrolled in the ACE program. In six months’ time, one-third of those patients reduced their emergency visits by 47%. Hospitalizations for the ACE group are down by 54%. Office visits are up 16% due to ACE’s focus on proper primary care to prevent more serious problems, says Grahn.
"We’re trying to do what’s right for the patient, and that really happens to reduce utilization and save money," he said. "The patients are getting a lot more phone contact. The patients who need it come to the clinic and get a much more complete evaluation of their care."
Coordinating specialist care
ACE monitors all aspects of the patient’s care. If the patient sees specialists for specific health problems, ACE case mangers coordinate visits and ease communication between the specialist and the patient.
"We have a clinical record that we share with the specialist. We track the patient’s visits to the specialist. If the patient has dementia, the case manager keeps close track of all his or her appointments, eases transportation problems, and addresses other barriers to treatment. We have a lot fewer no-shows now," says Brown Robinson. The ACE team provides such comprehensive care that many specialist visits can be eliminated, she adds.
"We’re getting very positive feedback from patients and families. They feel very well cared-for," says Brown-Robinson. "This is especially good news for Kaiser. We have a lot of adult children of ACE members who feel very good about Kaiser right now, and that’s good for us. They feel that the HMO is caring for their parents, and that keeps them with Kaiser, too."
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