Primary care — the new frontier for case managers?

Opportunities abound in physician offices

As payers and providers recognize the value of care coordination for people with chronic conditions and complex care needs, opportunities are opening up for case managers in primary care practices.

Consider these facts:

• Aetna has embedded or dedicated its own case managers to 75 provider facilities across the country where they work with physicians and staff to coordinate care for patients with chronic conditions and advanced illness.

• Primary care providers who participate in Cigna’s Accountable Collaborative Care program are required to employ care coordinators to act as a link between the patients, the providers, and the health plan.

• Advocate Health, a Chicago-based health system that includes 12 acute care hospitals and more than 250 sites of care, embeds case managers in primary care practices when the size of the patient population warrants it.

Case managers have new opportunities as the medical home model evolves and providers and payers recognize the value of care coordination, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY.

Physicians don’t have the time to spend with complex patients who need assistance in managing their conditions or illnesses. Case managers do have the time to work with patients and drill down to identify barriers to adherence that providers may miss, Mullahy says. “There is a 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 medical group practice, the insurer, and the patients benefit when case managers are embedded in a primary care practice to help patients manage their chronic conditions and stay out of the hospital, Mullahy says.

Colleen Holland, RN, CCM, loves her job as an Aetna case manager embedded in the Cleveland Clinic and works as a team with two Cleveland Clinic case managers to coordinate care for at-risk patients covered by Aetna’s Medicare Advantage plan who have been recently discharged from the hospital or who need help managing their chronic conditions.

Embedded case managers have the opportunity to build relationships with their patients and stay with them until they have good outcomes, Holland says. “A lot of times, nurses in a hospital setting follow patients for only a short time and never know what happened. Being a case manager gives me the chance to know that I am helping my patients over the long term. It’s very rewarding,” she says.

She contacts her patients by telephone and works with the Cleveland Clinic team to connect patients with other assistance beyond telephone coaching, such as community services and psychosocial support. The case managers work together to enroll the patient in Cleveland Clinic or Aetna programs that can help them manage their conditions and avoid readmissions.

“It’s more than just making phone calls. It’s helping them work through the system. The healthcare system is overwhelming to many people, especially the elderly. Some find it hard to call the doctor’s office and they are grateful when I offer to send the doctor a message to call them,” she says.

Many times, elderly patients are taking multiple medications and may not follow their discharge instructions when they get home. “They appreciate having someone to walk them through the discharge plan and tell them which medications to take. They know that I am just a phone call away if they need help, and when I call them, they sound happy to hear from me,” she says.

Embedded case managers can work closely with primary care physicians to determine patients’ needs beyond the reason for the office visit and to support the physician’s plan when between office visits, says Sharon Rudnick, vice president for outpatient care management for Advocate Health in Chicago. “They make sure the plan of care is going well rather than waiting for something to go wrong that will bring the patient back in or will result in an emergency department visit or hospital admission,” she says.

Most medical practices do not have an infrastructure in place to manage people who are not in the office, says Randall Krakauer, MD, national medical director for Aetna Medicare. Aetna has embedded or dedicated case managers in 75 provider care sites nationwide. Case managers can fill that gap by checking up to make sure the patient has gotten his prescription filled and understand the treatment plan, Krakauer says.

“When physicians see patients in a hospital and write a set of orders, they have a high level of confidence that their orders will be carried out. If they see them in the office, they have a low level of confidence that patients are going to follow their treatment plan,” he says.

That’s where an insurer’s expertise and experience in case management is invaluable, he adds. “We have case managers who are trained and experienced and who can produce good results. We take our capabilities and combine that with the medical practice to create something better than either of us can do ourselves, and that’s provide better care for our members and the physicians’ patients,” he says.

Embedded case managers know the work flow of the practice and build a good working relationship with the physicians and the rest of the staff, says Lauri Rustin, chief executive officer of Fairfax (VA) Family Practice, a physician practice group with 12 practice sites that participates in Cigna’s collaborative accountable care model. The practice has one care coordinator and plans to hire another one.

Physicians trust the care coordinator and welcome the information she can provide, Rustin says. “They have access to information in the electronic medical record to help them coordinate care, and because they have a good relationship with the staff and the providers, they can communicate with them quickly. They can gather information from the insurance company and the patient that helps the physician decide what course of treatment will be best for the patient. Then, they work with the patient to reinforce the patient’s plan of care,” she says.

One advantage of having care coordinators embedded in the physician practice is that when they call patients, it shows up on caller ID that the call is from the doctor’s office. “The perception is entirely different when a doctor’s office calls than when an insurer calls. Patients are more likely to answer a call from their doctor,” says Harriet Wallsh, director of collaborative solutions and effectiveness for Cigna.

Holland recommends being an embedded case manager if you are someone who wants to be on the cutting edge of healthcare and like working independently.

“Embedded case managers have to be able to prioritize their work and make quick decisions, such as whether to suggest that a patient go to the emergency room or instruct them to call their doctor. It’s not a job for someone who needs a lot of guidance or who prefers a slow pace,” she says.