Intensive CM keeps members out of hospital

High-risk members get face-to-face management

Since Tufts Health Plan launched its integrated care management model for Tufts Medicare Preferred, its Medicare Advantage plan, the Watertown, MA, health plan has seen significant reductions in hospital admissions and readmissions. The health plan began the program in mid-2011 to provide face-to-face case management for its high-risk Medicare Advantage members.

“We know that admission rates and readmission rates in 2012 were significantly lower than in 2011, but it’s hard to know if we can attribute these reductions to this program because we don’t have a comparable control group. Members who declined to participate are different so they are not comparable. We believe the program is having an impact because we have been working on readmissions since 2008, but they haven’t budged until we started our integrated case management program,” says Jonathan Harding, MD, medical director for senior products.

Some parts of the network were slower to implement the program and some of those provider organizations have not experienced the same amount of decrease in utilization, Harding adds.

The program provides face-to-face case management for the highest-risk population. Members eligible for the program may have a variety of chronic conditions, cognitive issues, incontinence, fall risks, polypharmacy issues, and other problems that geriatric patients face. They are identified through claims data and a predictive model and stratified as to complexity. Complex patients are assigned to a nurse case manager who has undergone additional training on managing members with geriatric conditions.

The health plan bases its program for complex patients on two nationally recognized care management programs. Case managers who work in physician practices follow the Guided Care model, developed at Johns Hopkins Bloomberg School of Public Heath to provide patient-centered, coordinated care to patients with multiple chronic conditions. When patients go from one level of care to another, the nurses have incorporated the Care Transitions Intervention developed at the University of Colorado, to facilitate transitions.

About two-thirds of the physician practices in Tufts Medicare Preferred integrated delivery network are de facto accountable care organizations and have their own case management support. Tufts Health Plan collaborates with other physician practices to embed its own case managers in physician practices that provide care for 2,500 or more Tufts Health Plan members. “The model is the same whether it’s their care managers or our care manager. The care managers follow the same standards and same content regardless of who their employer is,” he says. The complex care managers see the patients in person whenever they feel it’s appropriate, although most of the contacts and follow up are on the telephone.

The health plan’s case managers are assigned to physician groups depending on the size of the membership in the group. The case managers work in the field most of the time but come into the office every week for conferences, training, and to brainstorm and share ideas with their fellow case managers. They meet with the physicians and medical directors at each group practice to discuss complicated cases, problem solve, and analyze readmissions and process issues and to develop initiatives to improve outcomes.

The health plan also hosts a monthly meeting for the medical directors at all physician practices in its Medicare network. At the meeting, the group discusses changes in processes to improve outcomes and receives clinical education around geriatric care management. Representatives from the physician practices discuss their success stories and give their peers advice on how to initiate the same processes in their practices.

The team approach has helped to identify patients who have issues as they transition from one level of care to another and helped to address the issues to avoid unnecessary readmissions, Harding says.

Case managers throughout Tufts Health Plan have an average caseload of about 850 members. Case managers who work with the highest-risk population work with 80 to 100 members each.

The complex care managers follow the high-risk members in any setting. They see patients at their physician offices as well as going into members’ homes to conduct a comprehensive assessment and meet with the family and caregivers. The comprehensive assessment in the home includes evaluating the members’ home situations, screening members for depression, cognitive issues, and fall risks, and determining what the members need to stay healthy at home. The case managers work with the primary care providers on whatever services the members need, whether it’s a referral to a community agency or for a physical therapist to conduct a home safety evaluation, says Denise Kress, MS, GNT, BC, CHIE, director of care management for senior products. When needed, they help the members access financial assistance for medications, help with transportation, and other resources.

They work closely with case managers at hospitals and collaborate on discharge planning. “We try to work with the hospital case managers to identify underlying factors that may have caused the admission or readmission. In some cases, the member may have called their primary care physician and gotten a message to go to the emergency department. This is an opportunity for us to educate the member on choosing the appropriate level of care,” Kress says.

The health plan originally contracted with a vendor to provide care coordination for at-risk members. “We got a decent return on investment, saving about $20 to $30 per member per month, but we believed that we could provide better care and generate more savings if we integrated the program with the other programs the health plan has to offer,” he says.

The health plan also has wellness coordinators who make post-discharge follow up calls to all members two days and seven days after discharge. They follow standardized templates to find out if the members understand their treatment plans, have gotten their prescriptions filled, have follow-up appointments, and if they have questions or concerns. The wellness coordinators are not clinicians but are highly trained and can transfer the call to a nurse whenever appropriate.

Tufts Health Plan has developed standardized educational modules that care managers follow as they work with patients to improve self-management skills. They evaluate patients for health literacy and use the teach-back method as they coach members. The care managers work with the member to develop a member-centered action plan for meeting their goals.

“One of the challenges in healthcare is the tendency for clinicians to be paternalistic. We find out what is important to the members and use the information to develop goals,”Kress says.

The health plan’s transitions program helps identify patients with the highest risk of being readmitted. The health plan care managers utilize a day-of-admissions report with flags that may indicate the patient is at risk and determine what issues could be addressed while the patient is in the hospital. The information is incorporated into the discharge plan with the goal of mitigating those risk factors, Kress says.

“We have a standardized approach set up as patients are being discharged to make sure the patients have a primary care appointment within seven days and that the primary care physician has the discharge summary and medication list in a timely manner,” Harding says. If a member is being discharged to home from a skilled nursing facility, the health plan shares information on issues, like medication management with the visiting nurse, he says.

“If somebody goes home only to have to go back to the hospital, it’s compounding the negative effect on the member’s well being and health status,” Harding says. The health plan has developed a readmission task force to look at how the system is driving readmissions. The team is working with preferred hospitals to make sure the discharge summaries are generated on a timely basis. “In many cases, hospital by-laws give physicians up to 30 days to write a discharge summary. We want to change this. One hospital system has committed to have the discharge summary completed and to the community provider within 24 hours,” Harding says.