Medical home offers a chance to get to know your patients
Concept is growing as healthcare changes
As the concept of the patient-centered medical home grows in popularity, opportunities are opening up for case managers to work with patients on the primary care level to augment the care provided by physicians and spend the time necessary to help them learn about their disease and follow their treatment plan.
"Physician offices don't have the staff, the resources, or the time to educate patients and get them plugged into the resources they need to manage their conditions. That's where we come in, says April Moreland, MS, RN, a local care coordinator for CareFirst BlueCross BlueShield who works with patients in a patient-centered medical home in western Maryland.
CareFirst's case managers work from home, live in the territory they cover, and go into the physician offices as needed to see patients and collaborate with the staff. (For details about the program, see related article below.)
In other models, the case managers are employed by the practice or are health plan employees assigned full-time to a practice.
Moreland has been a staff nurse, a psychiatric nurse, a diabetes educator, and a nurse educator for a pharmaceutical company before becoming a local care coordinator.
"This position is very different from any other position I've had. I spend a lot of time with patients and have a lot of autonomy. The best thing about the job is that I get to work directly with patients and build a relationship with them. It's very satisfying to watch a patient get better over time. When you're a staff nurse, you don't get to see changes in patients because they are in and out so quickly, she says.
In today's healthcare environment, physician practices need to go beyond just treating the disease and assist with social factors and other barriers that make it difficult for patients to follow their treatment plans and stay on their medication, says William Gillespie, MD, chief medical officer for EmblemHealth, a New York City-based health plan.
"The complexity of care has grown astronomically as treatment options and medications have increased. No single physician can keep up with everything, and that's why team-based care has become so important. At EmblemHealth, our embedded case managers help close the gaps in care, make sure patients are seeing their doctor regularly and follow their diet and treatment plan, he says. (For more on EmblemHealth's program see article below.)
The emphasis on transitions between levels of care creates new opportunities for case managers who want to develop long-term relationships with their patients, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY.
"There is definitely a need in group medical practices for someone who has the knowledge, the skills, and the time to help patients access community resources, learn about their medication regimen and treatment plan, and ensure that they have recommended tests and procedures, she adds.
The embedded case managers take the entire person into account and not just what happens in the doctor's office, Gillespie says. "Case managers are a central part of the physician office. They get to know the physician's preferences and style and have the time that is necessary to explain the treatment plans and answer questions, he says.
Care coordination plays a major role in Horizon Healthcare Innovations' patient-centered medical home program, says Steven R. Peskin, MD, MBA, FACP, medical director for Horizon Healthcare Innovations, a division of Horizon Blue Cross and Blue Shield of New Jersey. "The care coordinators collaborate with physicians and work closely with patients. They have had a big influence on our reduction in hospitalizations and readmissions and our increase in preventative care, he adds. (For details, see related article below.)
Moreland and CareFirst's other local care coordinators work with physicians and patients to smooth transitions between levels of care and come up with ways to help the patients get their chronic conditions under control. "I become a specialist in their insurance. I know their coverage and their co-pay and if they have barriers, I can plug them into community resources, she says.
Moreland works with the physician and the patient to develop goals and a care plan. "The patient is always the center of the focus. If the goal we set isn't a goal of the patient, he's not going to be engaged, she says. For instance, one patient she works with is morbidly obese with hypertension and out-of-control diabetes. "He knows he needs to lose weight but his goal is to walk half a mile with his kids without getting short of breath. We implemented that goal into the plan. We know that if he walks, he'll lose weight and his blood pressure and blood sugar levels will improve, she says.
Another patient's goal was to swim for exercise, but she was embarrassed about her weight and reluctant to swim in front of other people. Moreland steered her toward a little-used pool at a community college and went with her on her first visit. "She was unaware of the program and she loves it. Often it's just her and one other person. Since she started swimming, she's lost weight and her joints don't hurt as much, she says.
The program allows her the flexibility to give patients the support they need. For instance, one patient gets dialysis every week at a hospital two miles from Moreland's home. "I see her every Thursday at the hospital. We both like the face-to-face visits, she says.
She goes to specialty appointments with patients and primary care appointments whenever possible. "If patients want my support and I can schedule it, I go to the appointments with them. When they visit a specialist, I can take that information back to the primary care provider, she says.
Many of her patients work during the day and are available only early in the morning or in the evenings. "I call some patients at 6 a.m. and others at night. I set aside Tuesday and Thursday evenings for calls. The hours are long, but I have a lot of flexibility. If I have a doctor's appointment myself, I can work that into my day, she says.
Care coordinators team with med home providers
Costs decrease, quality rises
CareFirst BlueCross BlueShield takes a team approach to care coordinators in its patient-centered medical home program.
The program is led by regional care coordinators, along with local care coordinators, and hospital-based care transition coordinators, all of whom work together and collaborate with the health plan's in-house case managers to make sure that CareFirst members get appropriate care in a timely manner.
"We have found the team approach to be successful in ensuring that our members receive excellent clinical care. The team communicates regularly and works closely with the physician practices to ensure that patients get the help they need to manage their care and optimize their health, says Jennifer Baldwin, RN, MPA, senior vice president of CareFirst's patient-centered medical home program.
CareFirst launched its first patient-centered medical home in 2011. Today the program includes more than 3,600 primary care physicians and nurse practitioners who provide care to more than 1 million members. In 2012, the second year of the program, costs for members covered by the effort were $98 million less than the insurer anticipated. CareFirst, based in Baltimore, provides insurance coverage in Maryland, the District of Columbia, and northern Virginia.
The regional care coordinators are the liaison between the physician and the health plan, while the local care coordinators work with patients and collaborate with physicians. The transition coordinators review CareFirst admissions to make sure they are appropriately triaged to the right care coordination services when they are discharged.
For the patient-centered medical home program, CareFirst has divided its coverage area into 20 sub-regions, each staffed by a regional care coordinator: a master's-level, highly experienced nurse who lives in the region, acts as liaison between the health plan and the physician offices, and supervises the local care coordinators.
The more than 100 local care coordinators also live in the area in which they work and are employed by a vendor with whom CareFirst contracts to provide care coordination for the medical homes. "It's important to the success of the program for the local care coordinator to live in the area. They know the hospitals, are familiar with the area, and often have a relationship with the local physicians through their previous employment, Baldwin says.
The local care coordinators work from home and are assigned to one or more physician practice, depending on the caseload at each practice. They go into the physician offices according to the member and practice needs and preferences.
"We yield to the practice preferences as to when the local care coordinators come to the office, whether it's just one morning a week, only in the evenings, or more frequently. We want to make sure we are welcome and are seen as an asset, Baldwin says.
The local care coordinators have experience in multiple healthcare settings, have good communication skills and organizational skills and must be able to work on a flexible schedule and with little supervision. "We've found that nurses with experience in only one facet of healthcare find the job difficult, Baldwin says.
The health plan uses an illness burden score to identify patients for the program. "It's based on diagnosis, not cost, because patients who don't go to the doctor may not have any costs but they may still be in need of care coordination, she says. Patients eligible for the program have multiple comorbidities, are taking multiple medications, have unstable conditions and barriers to caring for themselves, and need a care plan. "Patients who are managing well and are stable are not in the program even if they have multiple comorbidities or take large numbers of medication. We concentrate on the patients who need it most and have the greatest potential for becoming unstable, she says.
When patients are identified for the program, the local care coordinators meet with them on their next visit to the physician offices whenever possible. "We have found that a face-to-face meeting to introduce the program results in a better relationship, she says. They may follow up by telephone or see the patients in person, depending on the patients' needs and preferences.
The local care coordinators assess patient needs and collect pertinent information such as social history, living situation, and support system. When indicated, they also talk to family members or caregivers. After the visit, the care coordinator collects a vast array of information, including laboratory values, radiology reports and other test results when appropriate, past medical history, and information from all the physicians who are treating the patient. Using motivational interviewing techniques, the local care coordinator talks with the patient to set priorities, then distills all the information into a care plan. It could take as long a couple of weeks to get all the information needed.
"The care plan goes far beyond being a repeat of what is in the electronic medical record and provides invaluable information to the providers. It establishes the entire picture of the patient, not just what is seen in the physician office. We emphasize that the written care plans should be clear, concise, and compelling, Baldwin says.
The care coordinator then shares the plan with the regional care coordinator for approval and with the physician to obtain input. Only then is the plan activated by the physician. "The plan is activated only after medication reconciliation has been completed, and the physician approves. The physician is always the quarterback, she says. The plan evolves over time, depending on the patient's condition and adherence.
When patients are hospitalized, the care transition coordinator refers eligible patients to the local care coordinator or the health plan's case management program.
Patients with high acuity needs that can be quickly resolved, such as multiple traumas, are referred to the health plan case managers, who work with them by telephone for an average of three months until their conditions stabilize. When they are stable, they may be referred to a local care coordinator for follow up.
Patients who have multiple comorbidities and polypharmacy issues are referred to a local care coordinator in a patient-centered medical home. The local care coordinators work with patients for an average of six or seven months or as long as a year.
Frequent communication between team members is a cornerstone of the program, Baldwin says. "The local care coordinator role is not a common role for nurses. We teach each other a lot about effective care planning, she says.
CareFirst has monthly educational forums for all the care coordinators and weekly team meetings either in person or by video conferencing. The care coordinators share success stories and brainstorm on ways to deal with difficult patients. The day after the weekly team meeting, Baldwin contacts one local care coordinator from each region to find out what was valuable and what was frustrating and uses the information to set the agenda for the next meeting. "We always welcome feedback from the local care coordinators on how the process is working. Our ultimate goal is excellent clinical care, she says.
Care coordination slashes readmission rate
Medical home model takes team approach
When primary care practices that are part of EmblemHealth's patient-centered medical home initiative are supported by a multidisciplinary care coordination team to help smooth transitions between the hospital and the physician office, 30-day readmission rates have dropped from 17%-20% to 10%-12%.
"It's widely known that the hand-offs between most hospitals and most physician practices are not always smooth. We realize that by improving communication between the primary care provider and hospital discharge planner, we can make a dramatic difference in 30-day readmission rates, says William Gillespie, MD, chief medical officer for EmblemHealth.
EmblemHealth tested its medical home model during a two-year pilot project at 18 practices, then developed a relationship with 450 physicians in 39 locations who based their patient-centered medical home program on EmblemHealth's model.
Participating practices are supported by a multidisciplinary team employed by EmblemHealth that includes case managers, social workers, pharmacists, and health navigators. The embedded clinicians work as a team. The RN case manager can call on the social worker when patients have psychosocial issues or need community resources. They refer patients to the pharmacist for medication reconciliation. The navigators have bachelor's degrees and handle tasks that don't require a licensed clinician, such as setting up home oxygen, reminding patients of appointments, or other tasks requested by the case manager.
Physician practices have welcomed the EmblemHealth team, Gillespie says. "They understand the benefit of case management support as a way to help them improve the care for patients. In every case where we have embedded the team, the practices have found it helpful, he says.
Many of the patients who are in the program are identified while they are in the hospital. Every day, EmblemHealth sends the case managers a list of hospitalized patients who receive care by the practice they support. Other patients are referred by their physicians when they are having problems getting their chronic diseases under control or need community resources.
When patients are hospitalized is an optimal time to work with them to improve their health, Gillespie says. "This is a teachable moment and one where we can have the most impact. We have found that a hospitalization makes patients receptive to learning how to manage their health and avoid another admission, he says.
When the case managers are notified that patients are in the hospital, they call them in their hospital room, then get in touch with family members or caregivers. "If they don't already have a relationship with the member, they introduce themselves and say they are calling on behalf of the primary care provider and want to help the member get better and avoid returning to the hospital, Gillespie says. The case managers typically contact the family or caregiver every day during the hospital stay to help them understand the patient's condition and progress and what kind of care or equipment will be needed when the patient goes home. They keep them informed about the anticipated discharge date and help them prepare for the discharge.
The practice-based case managers work closely with the hospital discharge planners to develop a discharge plan. Clinicians at the practice and at the hospital share information that will help with discharge planning and give the primary care practice a picture of what happened in the hospital. "This close relationship helps provide continuity in care as the patient transitions from the hospital to home. In the past, the primary care physician might not have been aware of the hospitalization and medication changes, Gillespie says.
The case manager in the practice takes responsibility for the patient at the moment of discharge, Gillespie says. "The case manager contacts the patient right after discharge to make sure the patient has a follow-up appointment and understands the discharge plan. Patients are more likely to follow the treatment plan if they are contacted just after hospitalization, he says.
Before the appointment, the case manager informs the patient's physician about the hospitalization and what has occurred between the discharge and the appointment so the physician is well informed for the visit. The case managers typically see patients in person when they come for their follow-up visit with the primary care provider. In many cases, the physician refers the patients back to the case manager for ongoing support.
The case managers follow patients as long as they need assistance. "Some have an acute event and recover quickly, then go back to self-directing their care. Other patients have complex needs and the case managers may follow them for 60 to 90 days, he says.
The practice-based case managers can refer patients with chronic diseases or who need long-term management to EmblemHealth's disease management and complex case management programs.
The program is popular with the patients, he says.
"We have found that many patients who are engaged this way like it and form an ongoing bond with the case managers. Patients send them flowers and candy and often pop in to say hello when they are well, Gillespie says.
Care coordinators reduce costs, improve care
ED visits, admissions drop; screenings increase
A program that supports care coordination in patient-centered medical homes has improved care and reduced costs for patients within Horizon Blue Cross Blue Shield of New Jersey's patient-centered medical home program.
In 2012, the program reduced emergency department visits by 12%, hospital inpatient admissions by 23%, and reduced costs of care for diabetic patients by 9%. In addition, the program has increased diabetes control by 5%, improved breast cancer screening by 3%, and increased pneumonia vaccinations by 11%.
"These results demonstrate that we can improve quality and reduce costs at the same time, says Steven R. Peskin, MD, MBA, FACP, medical director for Horizon Blue Cross Blue Shield of New Jersey, the state's oldest and largest health insurance company.
Horizon worked with eight leading physicians and the New Jersey Academy of Family Physicians to develop the model for its team-based patient-centered medical home program. After the eight practices successfully implemented the model, the insurer expanded it to 20 practices in January 2012. Now there are 900 physicians in more than 100 practices participating in the model.
Care coordination is a key component of the program, Peskin says. The insurer provides additional funds for the practices to hire staff to coordinate care and offers bonuses to physicians whose patients reach preventive care targets. Horizon also requires practices to employ nurses to assist physicians and to offer a flexible appointment schedule in order to expand access for patients.
Larger practices have at least one full-time RN care coordinator, while the smaller practices may have part-time care coordination staff or share care coordinators with other practices, depending on the patient caseload and needs. The care coordinators collaborate with physicians, advanced practice nurses, and other members of the practice care team to ensure that patients receive timely, evidence-based care.
When the program begins in a practice, the practice sends customized letters to patients explaining the medical home concept and how the care team will work with them to improve their health. "Everyone in the practice is part of the medical home, Peskin says.
Patients who receive interventions are identified through claims data and by clinicians who identify at-risk patients based on their medical history. The care coordinators typically develop care plans for about 5% of the commercial population and 10% of patients who are in Horizon's Medicare Advantage plan. They help patients with chronic conditions follow their treatment plan, identify gaps in care and make sure the patient gets the recommended tests and procedures, and promote wellness and preventive care among patients.
It's up to the individual practices to decide how the care coordinators will work with patients, Peskin says. In some practices, the care coordinator meets with patients face to face when they come into the office. Other care coordinators contact patients by telephone to help them manage their chronic conditions. Some care coordinators hold periodic group visits for patients with the same condition. For instance, they may have a group visit with patients with diabetes to discuss diet, medication, and the importance of recommended tests and procedures. In some cases, they may perform foot checks.
When patients are hospitalized, the care coordinators are alerted through the daily admissions notices the health plan sends to the practice. They contact the hospital and talk to the care coordinator or the hospitalist providing care and share information about the patient.
"The care coordinators focus on transitions and the importance of getting the patient back into the practice within 72 hours of discharge, Peskin says. They follow up with the patient as needed. For instance, in the case of a patient who is hospitalized for a chronic condition such as heart failure, the care coordinator follows up with the patient to find out what went wrong and to emphasize the plan of care, such as following a low-sodium diet and checking weight daily. "The goal is to encourage the patient to follow the recommended plan of care and avoid any additional hospitalizations, he says.
There's no set way that the care coordinator functions within the team, he says. "They are notified of admissions and work on transitions from hospital to home and to the practice and update the care plan. Whether they meet with the patient or follow up by telephone depends on the preference of the practice in which they work, he says.
The care coordinators contact chronically ill and at-risk patients periodically, depending on the severity of illness and needs of the individual. For instance, they may follow up frequently after a patient has been hospitalized, or if they are having problems managing their chronic conditions. When patients miss a recommended follow-up visit, visit the emergency department, or have a gap in care, it triggers outreach from the care coordinator.
The entire team at the practice has huddles at the beginning of the day and reviews patients scheduled that day, especially those with chronic or complex conditions. The care coordinator often can provide background information that will assist the physician.
"The practices take a team approach to care. The physician or nurse practitioner is in charge, but other individuals who communicate with the patients can have a positive impact, he says. For instance, a medical assistant may perform a quick depression screen or ask the person about his diet. "The medical assistant may be trained to ask questions and take notes, getting the treatment team the information they need, he says.