CMs work with families, providers, community
Case managers at Beech Street Corp. in Lake Forest, CA, look at far more than the patient’s immediate medical problem when coming up with a plan of care. They also examine at psychosocial issues, financial issues, the home environment, and spiritual needs to help identify patients’ key problems.
"In case management, the medical diagnosis may not be what is driving the cost. It may be the financial picture or the home environment, says Teri Howard, RN, manager of health care management.
Beech Street offers a multifaceted case management program with the goal of achieving cost-effective quality care. The company’s case management department handles catastrophic illness and injuries as well as long-term illnesses.
"We take a collaborative approach with families, patients, providers, and insurers. We seek assistance from community resources and coordinate care with other agencies," Howard says.
Case managers from Beech Street often get involved with the family from the first day of hospital admission. "We help them understand what is going on, let them know their options for movement through different levels of care, and help them interpret their benefits package," she says.
Patients are referred to case management from a variety of sources. "We have an outstanding utilization review product which goes hand-in-hand with case management. As a result, most of the cases are identified early on, and we can take a proactive approach in helping patients move along the continuum," says Nancy Neslen, RN, senior director for health care management.
The company’s computer software is set up to flag more than 1,800 diagnoses of catastrophic injuries and serious or chronic illnesses that have the potential for case management.
If the case management flag comes up, when nurses take the pre-certification information, they automatically refer the case electronically to case management.
"The nurses in utilization management also use their judgment to refer cases to case management. For instance, if a patient has repeated admissions in a short period of time, it may be appropriate for case managers to look into the case," Neslen says.
The case managers also have referrals from payers when they have large dollar expenditures that do not necessarily result in hospitalization.
"In this case, they ask us to look at the patient to make sure they are getting the right care in the most cost-effective manner," Howard adds.
Talking with family members
Once a referral comes in, the case managers call the hospital discharge planner and assist in coordinating patient care. They call the family, explain who they are and what they are doing, and get a history of what has been going on with the patient, Howard says.
In a typical case, the case manager makes several phone calls to the family before discharge to gather information about the home environment, comorbidities and any other potential problems, and find out what is needed to keep the patient safe in that environment.
Once the case manager identifies the patient’s problems and needs, he or she works together with the physician, the family, and other providers to come up with a plan of action.
"The case managers make sure that the patient is in an appropriate level or care and is receiving the best possible care in the lowest-cost setting. They coordinate any additional needs, such as durable medical equipment or home health. We often request flexing of benefits if it will get the patient to a more appropriate level of care," Howard says.
Case managers also consult with Beech Street medical consultants and hospital discharge planners to identify potential needs up front.
"We identify the contracted providers in that area right up front and get referrals going so that at the time the patient is discharged, the bed is in place and home health is set to come out the day of discharge," Neslen says.
Chronic disease patient are referred to case management primarily when they are hospitalized and in crisis.
At that time, the goal is to stabilize them and get them to a lower level of care. After discharge, the case managers work to find out what caused the problems.
"Nine times out of 10, it’s lack of specialty care," Neslen says.
For instance, the patient may be an asthmatic with multiple prescriptions for oral medications and inhalers who doesn’t know how to use them. He is going from one physician for one medication and another for another medication.
"The patient is set up for failure. They end up in the emergency room. They do much better if we get them to a specialist for their care," Neslen adds.
The case managers help chronically ill patients modify their behavior and learn to manage their own illness. They provide educational materials from specialty organizations such as the American Lung Association and the American Diabetes Association.
The case managers contact patients on a weekly basis when they are in crisis. They check to see if they are taking their medicines and if they have made scheduled physician visits.
As their condition improves, they call less frequently until the patients are stable and independent and their file can be closed.
Beech Street case managers typically handle 35-45 active cases at a time, based on the acuity of the patient. For instance, a patient with a new spinal cord injury may require so much attention for the first few weeks that the case manager has a lower case load than her peers.