Face-to-face approach pays dividends

Health plan cuts readmissions

EmblemHealth’s team approach to providing face-to-face care coordination after hospitalization resulted in a 31% reduction in the 30-day readmission rate for members who received the interventions when compared to a baseline group.

In a study, after the New York-based health plan embedded a nurse case manager, a social worker, a pharmacist, and two health navigators into a large medical group to coordinate transitional care, the total number of readmissions per member dropped by almost 37% and the total number of hospitalized days was reduced by 43%. The savings were more than sufficient to cover the cost of the project, says Andrew Kolbasovsky, PsyD, MBA, director of provider group clinical management.

The pilot project, conducted at Manhattan’s Physician Group, was so successful that the health plan has rolled the model out at four offices of the medical group in Manhattan, two large offices at Staten Island Physician Practice, one office of Preferred Health Partners in Brooklyn and worked with Queens-Long Island Medical Group to train its staff to follow the same model.

The health plan explored ways to reduce the cost of hospitalization, the largest driver of health care expenses, Kolbasovsky says. “There were limitations in reaching our members via telephonic case management. It’s often harder to reach members and hard to engage them over the telephone,” he says.

For the pilot project, the health plan identified a large medical group with several offices in Manhattan where a significant number of members were treated. Instead of embedding only a nurse, EmblemHealth decided to embed a team to take care of the diverse needs of members.

“With this arrangement, the care managers and other team members can see the members in person and call in other members of the team as needed. The situation offers the advantage of quick interaction with the physicians if the case managers needed to talk with them,” Kolbasovsky says.

The team includes a nurse case manager, a social worker, a pharmacist, and two health navigators. “Some of our members have social needs, mental health issues, and financial problems, which makes a social worker a valuable person on the team. We also saw a growing need for a pharmacist to help with medication reconciliation,” he says. The health navigators are not clinicians but have experience working with members, have good communication skills, and are knowledgeable about the kind of information that members need.

Every day, the EmblemHealth headquarters reviews data from hospitals and identifies members who are medically hospitalized and shares the information with a member of the point-of-care team. The list includes all members, with the exception of maternity patients, who are being treated at the office where the team is embedded. Medicare, Medicaid, and commercial members are included. A high percentage of hospitalized patients are older members who receive Medicare benefits.

The health plan reaches out to any member who has been hospitalized. The team makes its first contact when the member still is in the hospital and begins providing interventions. Some already have a stable home environment and the resources they need. Others have extensive needs.

One of the primary objectives is making sure the patient has a follow-up appointment within seven days of discharge. The case managers or other team members tell patients they work with their doctors and are going to make sure they have everything they need. They make arrangements to meet with the patient before the follow-up doctor’s appointment.

“This is our chance to prepare the members for their first visits with their doctor and help them decide what questions to ask. If the member is confused about his treatment plan or medication regimen, the case manager or other team member will give the doctor a heads up,” Kolbasovsky says.

Although the team works together, one person takes ownership of the case and is the primary contact for the patient but is backed up by the other team members. “Each member of the team can bring the others in. It allows us to help a lot of people,” he says.

The health navigators typically work with the members with less complex needs and call in other team members when needed. For instance, if the member is on a lot of medications or has had a change of medication, the pharmacist goes over the medication either in person or over the telephone. If the person seems to be depressed or needs community resources, the social worker steps in.

As people are being discharged from the hospital, the team makes sure they have a timely follow-up appointment, makes sure they understand their medication and know how to fill their prescriptions, and tries to identify cost issues and work them out. The team member working with the patient conducts a needs assessment and links the member to needed resources. In addition to community resources, the team may refer members to health plan services such as disease management or hospice care, or medical group resources such as a nutritionist or diabetes educator.

“We are finding a lot of members who have difficulty traveling to the doctor’s appointments, and others who need assistance with housing or meals. We help all of those qualify for and access community programs,” Kolbasovsky says.

The team works with physicians to identify red flags for readmissions. “A lot of patients don’t call their doctors until their symptoms get so bad they need to be hospitalized. Our care management team teaches them how to identify early warning signs and build a plan for action,” he says.

Members typically are in the point-of care program for 30 to 60 days at a time.

“We constantly assess the members’ risks and needs and connect them with whatever services they need,” he says.

The program started out with the goal of reducing 30-day readmissions. “We’ve seen a nice reduction in readmissions, but what surprised us was the other impacts we made on members and their families,” he says.

The team makes connections with the members’ families and works with them as well. “Family members often feel alone and afraid when their loved one has been in the hospital, and they welcome having someone to advocate for them and help them navigate the healthcare system. Because the case managers and other team members see the patient in person, often with their caregivers, they can create strong bonds,” Kolbasovsky says.