Embedded CMs cut admissions, LOS

Good relationships are key to success

Since Advocate Health Care began embedding case managers in primary care offices, hospital admissions and emergency department visits have decreased and length of stay has dropped, says Sharon Rudnick, vice president of outpatient care management for the Chicago-based health system. Advocate Health Care includes 12 acute care hospitals and more than 250 sites of care with about 4,000 physicians, a quarter of them employed by the health system.

It’s all about building relationships, Rudnick says. Care managers, who work on site directly with physicians, know what is expected and how to support a treatment plan between visits. “Our dedicated care managers work very hard to develop close working relationships with the physicians,” she says.

The arrangement also helps the care managers cement their relationships with the patients whose case they are coordinating, she adds. “When patients know that care managers are part of the physician office team, it helps build trust more quickly than if someone they know nothing about approaches them,” she adds.

The larger practices have care managers on site who meet with patients when they come in for visits and follow up by telephone. In smaller practices, they work with patients by telephone. Each care manager is assigned by physicians and works as a team with his or her providers. “This way if a patient calls into the physician office and wants to talk to the case manager but doesn’t remember the name, the front desk staff knows instantly who should get the call,” Rudnick says.

Patients in the program are identified by predictive modeling or referrals from the emergency department, the acute care hospital, a post-acute facility or their physician.

“Physicians may know that a patient already had an acute event or is having other problems and they can anticipate that they will need care coordination,” she says.

Care managers reach out either in person or over the telephone and work with patients to create individual care plans that engage patients in their own healthcare. They work to identify patient needs that can range from gaps in care to psychosocial issues. “The care managers look beyond the patient’s physical needs and link them with resources that can help. For instance, a patient with diabetes also may be struggling to care for an elderly parent and needs assistance,” she says.

Care managers use a case management tool that helps them assess the patient and prompts them as to which questions to ask.

Depending on the physicians’ preferences, care managers meet with the patients during the office visit or come in at the end as the physician is leaving.

Recognizing that patients don’t always remember everything the physician told them, the care manager reminds them by saying something like: “remember when Dr. Jones told you ...” and the instructions come back into their minds, she says.

The care managers have a caseload of 80 to 120 patients with both Medicare and commercial insurance.

Advocate Health Care’s care managers are either RNs or social workers and are trained on motivational interviewing and engaging patients.

“The nurses and social workers each have their own strengths. If it’s a complex clinical case, the social worker may need assistance from the RN. If the nurses need help in working through the barriers to care, they can call on the social workers,” she says.

The majority of patients receive care in 12 hospitals in the Advocate network. The primary care case managers share information with their counterparts in the hospital and work with them on a smooth transition. Then at discharge, the primary care case manager picks up the case again. “It makes our patients feel cared for across the continuum and helps facilitate good transitions in care,” she says.