Discharge Planning Advisor

Initiative cuts ED visits, hospital admissions

Phone monitor’ role gives continuity to program

When Sutter Health Central in Sacramento, CA, got involved in managed care and global capitation several years ago, it made sense to identify the patients likely to use the system a lot and do interventions to prevent them from getting to that point, says Jan Van der Mei, RN, continuum case management director.

That goal led to the development of the Sutter Chronic Care Program, an initiative that, among other benefits, reduced participating patients’ visits to the emergency department (ED) by 43%, admissions to skilled nursing facilities (SNFs) by 36%, and acute care admissions by 32%, for the period between July 1, 1999, and June 30, 2000.

Preventing frequent flyers’

There were similarly dramatic reductions in outpatient visits, home health visits, and visits to both primary care physicians and specialists. Although those results are for members with high utilization rates — two or more acute admissions, two or more ED visits, or five or more home health visits within a year — the program also focuses on patients who are not "frequent flyers," Van der Mei says. "We are trying to prevent that from even happening," she adds. "We may have 800 enrolled in the program, but only about 400 meet that [high utilization] criteria."

For all the patients, who are Medicare+Choice enrollees, the health system is financially responsible for physician visits, hospital admissions, SNF costs — "everything but pharmacy," she adds.

The chronic care program began in 1995, the brainchild of gerontologist Cheryl Phillips, MD, who was given a dual mission by Sutter Medical Group, an association of physicians that is aligned with Sutter Health Central. "We had about 3,000 Medicare HMO enrollees, and we realized there was a subgroup that was very frail and used a lot of services." The idea, she adds, was not only to focus on preventive care for frail elders, but also to address the common problem of trying to fit chronic care into an acute care model.

Volunteering her time, Phillips says, she began the effort with a half-day social worker and a half-day nurse practitioner, and wrote the risk screening tool for the program on her home word processor. "We developed risk stratifications, not only to identify the risk levels of those with chronic diseases, but to hit the threshold for our definition of frailty." Taking a handful of patients and doing home visits, she explains, Phillips and her team developed a longitudinal, or ongoing, case management model to replace the traditional episodic, or reactive, care model.

Identifying frail elders

With some funding from three health maintenance organizations (HMOs), she was able to add a functional operations manager, Phillips says. "At that time, our managed care enrollment was growing, and we did broad-based screening of enrollees." By mailing out a questionnaire to new enrollees in Medicare+Choice, she adds, "very often we would find frail elders before the primary care physicians did."

In the program’s initial stage, Phillips explains, her role was "very patient-specific. I would do initial assessments with the nurse practitioner, and screening reviews." Now that the chronic care program has grown to nearly 1,000 patients, she says her role as medical director is to set policies and criteria for frailty, meet with the care team on a regular basis to go over difficult or challenging cases, and act as a liaison between the primary care physician and the team.

"We often find [cases of] multiple medications, untreated depression, and new dementia," Phillips explains. "I can communicate with the primary care physician [PCP]. It was never our goal to assume the role [of the PCP], but we serve as the coordination for them."

Providing links between agencies

The chronic care team links regularly with home health agencies and nursing homes so that it is aware when a member is using these services, she says. "We can serve a lot by providing links and assisting with placements, particularly if the patient is in the nursing home for a short time, like for rehabilitation after a stroke. We become that continuity link. If they go in the nursing home and go back home, we know about them across the continuum and coordinate the levels of care."

The health risk screening tool that Phillips developed, Van der Mei points out, defines four levels of risk. "They primarily followed 3s’ and 4s,’ she adds. Those at level 4 are at great risk, and those at level 3 are at risk of potentially needing hospitalization."

The chronic care program "started as a social work model," she says, assisting members who needed caregivers, food, or transportation. "We do a lot of those interventions, helping patients with chronic illnesses maintain a level of functioning." Now, however, with the addition of more nurses, "it’s more of a multidisciplinary team," she adds.

A statistical analysis of the participants at the end of the initial grant period validated that the screening tool was a predictor of increased utilization, she says. At that point, notes Van der Mei, the program "needed to be operationalized. We had the concept, but needed to find a way to fund it when the grants ended, and without a definite return on investment, it was difficult to fund."

Based on the early results, however, Sutter’s physician group and hospital administration agreed to provide funding, she says, and Van der Mei was hired in August 1997 to develop and expand the program. After studying different chronic care models, she developed for the program the role of monitoring specialist, or "Medicare risk specialist," Van der Mei explains. "For ongoing monitoring, you don’t necessarily need a nurse or social worker, but you do need someone with a background in the field of gerontology."

This brought an additional member to the multidisciplinary team, one who is able to carry a larger caseload, she says. When the monitor identifies a problem, there is a nurse or social worker close at hand who can be consulted, Van der Mei adds. "The monitor can say to the nurse, You need to go out and do a home assessment.’"

At present, she says, the team is made up of four registered nurses, four social workers including one who is the team supervisor, three Medicare risk specialists, and support staff. Each RN case manager and social worker has a caseload of between 60 and 80 patients, while the phone monitors carry a caseload of 150.

Ongoing monitoring for at-risk patients

The ongoing monitoring provided by the Medicare risk specialist is not hands-on and not episodic, Van der Mei points out. "Our patients don’t have to be homebound. They’re just at-risk patients, patients who are very frail."

In a typical case, Phillips explains, the team identifies a high-risk patient, either through its screening tool or through referral from a physician. The patient may be, for example, an 89-year-old woman who is falling a lot, not taking her medications, and living alone. The initial assessment is done by a nurse, a social worker, or both, depending on the patient’s needs, she says. The team identifies the problem, develops interventions, and coordinates the care by, for example, bringing in a physical therapist and safety equipment and lining up community services.

Once these solutions are in place, the case is handled through telephone monitoring by the Medicare risk specialist who calls the patient every two weeks, and eventually monthly. That monitor "keeps the link to make sure things are working. It’s also a constant link for the patients, so when they have a problem they know who to call," Phillips adds.

"Sometimes the interventions are up to the family members," Van der Mei notes. "The monitor can call and check to see if the family has followed through on what it’s been identified that they need to do."

The program differs from many other models in that it is over time, she adds. "Many times patients stay in the program until they die, or for a year, or they may move to assisted living or a SNF." If the patient does move to a SNF or similar environment, she says, "we back out at that time" because of the close care the person will receive in such a setting.

In most health care systems, Van der Mei says, "there’s not really anybody that does this [function]. With our program, instead of calling physicians all the time, the client calls the chronic care program. We help coordinate that maze of confusion in a managed care system. The program, she adds, "is an extension of the PCP."

The chronic care team teaches patients to recognize symptoms earlier that indicate they should visit a physician, Van der Mei says. The team will make the appointment for them, if necessary. "We do medication management. If, for example, patients are taking eight to 10 drugs, we make sure the physician knows they’re taking them all." If patients run out of money and can’t fill their prescriptions, the team can help them apply for MediCal or other assistance programs.

Plenty of challenges

The program has not been without its challenges, Van der Mei notes, including the difficulty some physicians have had understanding its role. "Sometimes they expect you to work miracles you can’t," she says. "[Physicians] say, The patient needs to be in a SNF today, but maybe the patient doesn’t want to go today. We work with them over time. Patients have a choice, and sometimes they make bad choices."

Another problem is that the program is only for managed care patients, while physicians have patients with all kinds of payers in their practices, Van der Mei points out. "It’s difficult for [physicians] to keep up with who they can refer to this program."

One of the earlier misunderstandings, she says, was that some people thought the program was the same as a home health agency. "We don’t do wound changes, injections, intravenous antibiotics — anything that is skilled and short-term."

At times, however, the program has overlapped with a home health agency, Van der Mei says. "At first they saw us as a threat. We try to avoid getting involved until the home health [service] is closed, but sometimes there’s a social issue, if a patient doesn’t have a caregiver, lives alone, and is falling, for example. Maybe home health is taking care of the patient’s wounds, but doesn’t address the big picture."

[For more information on the Sutter Chronic Care Program, contact:

Jan Van der Mei, RN, Director, Sutter Health Center, Continuum Case Management, Sacramento, CA. Telephone: (916) 854-6896. E-mail: vanderj@sutterhealth.org.]