CM, benefits collaborate to ease transitions
Health plan takes proactive approach
In order to improve transitions between levels of care, CareOregon has developed several initiatives to ensure that members get what they need after discharge.
- The benefits management and case management departments have been combined, and the concurrent review nurses notify case managers immediately when members are hospitalized and alert them to discharge needs and concerns.
- As part of a pilot project, a case management supervisor visits eligible members in the hospital, explains the transition case management program, and obtains contact information.
- Transition case management nurses follow up with patients within three days after discharge, educate them on their disease and treatment plan, and coach them on questions to ask their doctors.
In order to provide better post-discharge care coordination for members with complex needs, CareOregon has aligned its case management and benefits management programs and is piloting a project to see patients face-to-face while they are still in the hospital.
"By bringing case management and benefits management together, we can provide better care coordination. The minute we know members are in the hospital, the concurrent review nurses notify the case managers. As they review for continued stay, they keep the case managers informed about what’s going on so they can have the information they need to coordinate care in real time," says Claire Greco, RN, MPA, CPHM, senior manager, care management for CareOregon.
To increase the number of members who are engaged in the transition case management program, the health plan began a pilot project in August and sends a case management supervisor to visit eligible members in the hospital, explain the program and the services the case manager can provide, and verify contact information. "People may go to a family member’s or friend’s home after discharge and we can’t get in touch with them. We make sure the case managers have a number to call, tell the patients and family members the name of the nurse that will be calling them after discharge, and let them know to expect the call," Greco says.
The health plan stratifies members as to their risk level using their recent history, conditions, and other data. Those who meet the criteria for complex care management are enrolled in the transition program for 30 days and the complex case management program for 60 additional days.
The health plan’s care concurrent review nurses follow members identified for the program in the hospital and work with the discharge planner to identify patient needs and alert the transition case managers about the members’ discharge needs and concerns. For instance, if the patient has a prescription for a drug that requires authorization or durable medical equipment that is difficult to obtain, the concurrent review nurse and case manager know ahead of time and can set things up in advance so the patient has everything he or she needs for a timely, safe, and effective discharge.
When members targeted for the program are discharged from the hospital, transition case managers follow up with them by telephone within three days and cover a specific list of information. The interventions are based on the Care Transitions Model developed by Eric Coleman, MD, MPH, which aims to prevent readmissions.
Transition care managers make sure patients understand the medication regimen and care plan, and have a follow-up appointment with their physician. Care managers talk to patients about their conditions, educate patients on self management, and make sure they know the signs and symptoms that indicate they should call their doctor or go to the emergency department.
The case managers coach members on how to talk to their physicians and encourage them to write down questions and take them to their follow-up appointment. They find out the members’ support system and who can help them with their post-discharge needs and help them get to their appointments. They go over the member’s current health status, plan of care, and medication list and give them a number they can call with questions or concerns. "We educate the members on what they need to do to stay healthy and avoid trips to the emergency department or unplanned admissions and let them know that we’ll be available for 30 days if they need us," Greco says.
Following the first phone call, the case managers have a goal of following up two more times. "Sometimes we make only one contact and sometimes it takes many more than three calls before the member is stable," she says.
The case managers talk with the caregivers if the member gives permission and coordinate with the primary care providers. They refer the members to community services if there are needs that are not covered by the health plan.
"The goal is to make sure members get all the services they need after discharge, learn to manage their own care so they will have optimal outcomes, and avoid unnecessary readmissions and emergency department visits," Greco says.
