Acute Care Transitions program cuts ED visits

Embedded CMs work with patients in hospital

Keystone Mercy Health Plan’s Acute Care Transitions program, which embeds case managers in hospital emergency departments to work with patients who seek treatment or are hospitalized, reduced emergency department visits by 21% and hospital inpatient admissions by 32% over the course of a year among members who received interventions when compared to a control group.

The initiative also reduced per-member, per-month costs for participants by 24% over a one-year period at one participating hospital. By contrast, the per-member per-month cost for the group that did not receive an intervention dropped just 1.3% in the same time period.

When the Acute Care Transitions program was instituted, the health plan embedded case managers in the emergency department at Mercy Fitzgerald Hospital in Darby, PA. After the success of the program, the health plan placed Acute Care Transition case managers in two other hospitals where a large majority of Keystone Mercy members receive treatment, according to Cassandra Holloway, RN, MBA CCM, senior manager of utilization management and supervisor of the Acute Care Transitions program.

The program targets people who have heart failure, diabetes, asthma, and chronic obstructive pulmonary disease, but the Acute Care Transition case managers work with members who visit the emergency department or are hospitalized with other conditions. “They see everybody who is a Keystone Mercy member and reach out to them to make sure all is well,” Holloway says.

The health plan mines its data to identify members who have the targeted conditions or have multiple emergency department visits. “If someone shows up in the emergency department, the case managers know it right away and can visit with them to find out if they need additional support,” Holloway says.

The case managers cover the emergency department 8:30 a.m. to 5 p.m., Monday through Friday.

When the Acute Care Transition case managers come to work every day, they get a list of patients who visited the emergency department or were admitted overnight or over the weekend and follow up with them. They access the health plan’s medical management system and review the patients’ history, doctor visits, and pharmacy claims and determine if they need outreach. If patients are still in the hospital, they visit them in person.

When members have had an emergency department visit, the case managers contact them by phone, find out why they visited the emergency department instead of their doctor, educate them on their conditions and medication regimen, discuss the importance of regular visits to their primary care physician, and help them overcome barriers to following their care plan. They notify the primary care physician of the emergency department visit.

“The Acute Care Transition case managers are the first point of contact with patients, and by meeting with members in the emergency department and the hospital, they put a face on the health plan. It’s a good way to begin to build rapport and identify the services that people need,” Holloway says.

When members are hospitalized, the case managers reach out to find out if they need equipment, help with medication, or have other barriers to following their treatment plan and receiving follow up care. They work with the hospital case manager and the rest of the treatment team to coordinate the discharge and make sure the patients have everything they need after discharge.

The Acute Care Transition case managers send discharge instructions to the patients’ primary care physicians within 48 hours after discharge. The case managers update the telephonic case manager, inform the patient if the case manager has been unable to reach them by telephone, and gets updated contact information. If the members don’t have a telephonic case manager, they put the wheels in motion to get them assigned to the case management team.

When patients need additional help, the Acute Care Transition case managers will refer patients to the health plan’s Rapid Response and Outreach Team for assistance with ongoing health or social support issues. The Rapid Response and Outreach Team helps patients access community services and follows them until they are stable.

“We help them get whatever they need to keep their condition under control and avoid emergency department visits and hospital admissions. Many times, it’s a combination of a lot of things falling into place at the right time,” she says.