Home health CMs provide care, coordinate services

They act as the physician’s eyes in the home

At Integrated Home Care, nurse case managers provide hands-on care as well as handling the traditional case management duties, such as evaluating patients, developing a customized plan of care, coordinating with other members of the health care team, and arranging services such as social work or dietitian services.

In most cases, the Integrated Home Care case managers do skill assessments and assess patients for medication adherence as well, says Denise R. Edgett, PHN, manager of the agency, which is a division of Bloomington, MN-based HealthPartners Inc.

"They are very much responsible for the overall implementation and coordination of the client’s home care services," she adds.

Every patient who receives home health services is assigned a case manager. The agency has both nurse case managers and physical therapy case managers.

The RN case managers are responsible for supervising care by other providers such as LPNs or home health aides. If a patient needs physical therapy but not nursing care, the physical therapist assumes the role of case management, coordinating the patient’s care, collaborating with physicians, and supervising the therapy assistants or home health aides.

Educating patients

Many of the patients who need skilled care and meet the criteria for home care have chronic conditions and comorbidities, such as congestive heart failure and chronic obstructive pulmonary disease.

The nurses perform hands-on wound care, handle the infusion therapy and other medications, change catheters, and do a lot of disease management teaching. They may teach caregivers or the patients themselves about self-care or educating them about their medications. If a patient needs help with bathing, dressing, or other activities of daily living, they are assigned a home health aide, often a certified nursing assistant.

"Our agency has always had a model where case managers are never exclusively on the telephone. They have hands-on contact with the patient and often know the patient better than the physician, acting as the physician’s eyes in the home," Edgett says.

Whenever possible, the case manager who will handle the patient’s home health care makes the first visit and conducts the assessment.

The agency does have admission clinicians who do the first visit when the case manager can’t. The case manager who is going to handle the patient’s care does the admission visit about half of the time.

The case managers are responsible for scheduling the services the patient needs and either providing the care themselves or working with an LPN partner and delegating the care.

All of the case managers have laptops that allow them to work remotely as well as in the office. About half of their time in an eight-hour day is in direct care. During the rest of the day, they perform administrative functions such as coordination of care, documentation, and travel.

A full-time RN case manager typically handles a caseload of 27-36 patients with mixed acuity. Typically, they see a few patients only once a month and may see others several times a week or even daily.

The case managers are primarily assigned by geographic area.

"Our work is to serve patients in their homes. Case managers average about 12 miles each visit and generally are in the home 30-40 minutes," Edgett says.

The case managers’ laptops give them a complete medical record when they visit the home and the ability to do most of their documentation on the spot.

"Our most successful case managers are people with excellent organizational and time-management skills. They work their documentation into the rhythm of the visit and don’t leave a large list of things to do at the end of the day. Otherwise, they’ll have a very long day," Edgett adds.

Generally, the nurses see five or six patients a day while the therapists see about five patients a day.

Most of the patients handled by Integrated Home Care need skilled care intermittently and receive services on a short-term basis.

For instance, a patient may have been hospitalized with an exacerbation of congestive heart failure and may need home care for a short time to ensure that he or she is medically stable and knowledgeable enough to adhere to his or her medication and diet.

Another patient may be home from the hospital after hip or knee replacement surgery and need short-term rehabilitation therapy. Others with long-term chronic conditions may need assistance with funding sources, such as community waiver programs, to receive ongoing help with their activities of daily living.

"As our population ages, there are more patients who need home care and qualify for home care under their insurance," Edgett explains.

However, she points out, if a patient can come into the outpatient setting, the insurance won’t cover home care.

Integrated also has a small telehealth program focusing on congestive heart failure and chronic obstructive pulmonary disease patients to provide help above and beyond the face-to-face visits.

Case managers conduct telehealth visits with some patients, using a unit that looks like a computer monitor with a camera and transmits via a telephone line. Nurses in the office can connect with patients, see how they look, and measure vital signs such as blood pressure, heart and lung sounds, and weight. They talk with the patient and do assessments and teaching through the telehealth visit.

"At this point, there is only one payer in Minnesota that reimburses us for telehealth. We don’t consider reimbursement when evaluating eligibility for the program, but obviously the patient has to have the cognitive skills and dexterity to operate the unit. With some patients, the telephone line can be a barrier if the phone is frequently disconnected," she says.