Get up-close and personal with your patients

Face-to-face contact helps CMs build trust

When Catherine M. Mullahy was a practicing case manager, she received a referral to manage the care of a patient who was recuperating at home on short-term disability, after being hospitalized with a severe case of cellulitis.

When Mullahy visited the man in his fourth-floor walk-up apartment, she discovered that he was morbidly obese and living in a filthy apartment, strewn with open cans of beef stew. His leg was reddish purple and was propped on a dirty pillow. While Mullahy was assessing the man, his cat jumped onto his leg and started licking the wound. She ended up using numerous community agencies and providers as she coordinated care for the patient.

"My care plan for this man would have been so vastly different if I had just been talking to him on the telephone because I wouldn't have known about the all of the psycho-social issues," says Mullahy, RN, CRRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY, case management consulting firm. "Coordinating care, especially for complex patients, is like putting band aids on a gaping wound if you don't find out the back story, and you can't find that out except when you see patients face-to-face."

Face-to-face case management is gaining recognition as an effective way to manage the care of patients with complex medical and psycho-social needs, says Margaret Leonard, MS, RN-BC, FNP, senior vice president for clinical services at Hudson Health Plan, with headquarters in Tarrytown, NY. Many federal and state grants require face-to-face case management interventions, she points out. "In addition, patient-centered medical homes and the new Medicaid health homes also utilize case managers who see their clients in person. Medicare and Medicaid have started to recognize that people who present with certain risk factors are difficult to assess over the telephone," she says.

When case managers meet their clients face to face, they create a bond. "We have a lot of anecdotes about how meeting with case managers and building trust helps people turn their lives around. Getting to know patients personally is more satisfying to the staff as well," Leonard says.

By meeting with the family and patient in person, you pick up on family dynamics, says Sharon Gauthier, RN, MSN, iRNPA, owner of Patient Advocate for You, a Hartford, CT, patient advocacy firm. "When the family sits together and talks, I see how the patient and spouse react to the other family members, and I get a sense of what's going on from the body language they use. I find out things I never would know if we didn't meet face-to-face. I couldn't get what I need to know to manage my patients if I relied on talking to them on the telephone," she says.

Seeing patients in their home gives care managers in the organization's community care management program a lot of information they couldn't get over the telephone, says Sherry Marcantonio, MSW, ACSW, senior vice president for Health Quality Partners, a Doylestown, PA, nonprofit healthcare quality research and development organization. (For details on HQP's community care management model, see related article, below.) "In order to develop a long-term, person-centered relationship, the care managers need to see their patients in person, develop relationships with them, and build trust. When we see patients in their homes, we get a much better picture of how they are managing from visit to visit," she says.

While it's more expensive to send a case manager into a person's home, it makes a big difference, particularly with patients who have complex needs, when the case managers sees them in person, Mullahy adds. "Because case management is a relationship-based model of care, this, too, is enhanced when on-site visits can occur," she says.

Case managers can't accurately assess a patient's hearing or vision deficits over the telephone, Mullahy points out. They can't be sure what the patient is eating, if they can manage their daily housekeeping and grooming chores, whether there are safety hazards in the home, or whether the patient is taking his or her medication correctly. "In the long run, seeing patients in person at least once winds up being more cost effective than trying to figure out their problems over the telephone," she says. Everyone benefits. the physician, the case manager, the social worker, the patient and family members, and payers, Mullahy says.

To effectively manage the care of patients with complex needs, case managers need to see the home situation, the interaction between patients and family members or caregivers, and understand how the person functions. "It's hard to understand a person's situation and needs over the telephone, particularly if you live in a high-rise apartment in the city, and the client lives in a rural area, a trailer park, or a homeless shelter," Mullahy says.

Hudson Health plan has incorporated face-to-face case management for the most difficult to manage, and highest cost patients throughout the health plan, Leonard says. Case managers and social workers work with their clients face-to-face as well as over the telephone. The case manager or social worker who conducts the face-to-face assessment continues to follow the patient, mostly by telephone, and consults with his or her counterpart in the other discipline to get the information needed to manage the person's care.

"When someone has met the patient face-to-face, they begin to build a relationship, and having the same clinician follow up over the telephone creates continuity in care," Leonard says.

When safety is an issue, case managers and social workers conduct assessments in pairs, in the home or in a public place such as a fast-food restaurant or laundromat. They pay for clients to take a bus or taxi to the health plan headquarters if it's more convenient.

"Seeing patients face-to-face allows us to meet the people where they are and determine if they are ready for change. They may not feel comfortable talking with someone they never met over the telephone," Leonard says. "When our case managers and social workers see clients in person, they start building a relationship and can find out the psycho-social needs that have to be addressed before the patients can start changing their lifestyle and health habits."

Face-to-face case management represents a return to the way case management was conducted in the early days of the profession, Mullahy points out. In the past, workers compensation companies hired nurses and rehabilitation counselors from each state to manage the care of injured workers in their community because they were familiar with the rules and regulations governing that kind of coverage in their states. Later, as commercial insurers began case management programs, they found that telephonic case management was a cost effective option because benefits didn't vary from state-to-state and they no longer needed to hire local nurses.

"The healthcare system is beginning to recognize that in many situations clinicians need to get out and find out what is going on in order to effectively manage a patient's care. Factors like dilapidated housing, financial issues, dysfunctional families, and problems with activities of daily living are difficult to identify over the telephone but all can make it challenging to manage a patient's care."

Sources

For more information, contact:

  • Sharon Gauthier, RN, MSN, iRNPA, Owner of Patient Advocate for You, Hartford, CT. E-Mail: sharon@ptadvocate4u.com.
  • Margaret Leonard, MS, RN-BC, FNP, Senior Vice President for Clinical Services at Hudson Health Plan, Tarrytown, NY. E-mail: mleonard@HudsonHealthplan.org.
  • Sherry Marcantonio, MSW, ACSW, Senior Vice President for Health Quality Partners, Doylestown, PA. E-mail: Marcantonio@hqp.org.
  • Catherine M. Mullahy, RN, CRRN, CCM, President and Founder of Mullahy and Associates, Huntington, NY. E-mail: cmullahy@mullahyassociates.com.

In-home case management cuts cost of care

Chronically ill experience fewer hospitalizations

Medicare patients with chronic illnesses experience fewer inpatient hospital admissions and lower medical costs when they participate in Doylestown, PA-based Health Quality Partners' (HQP) community-based care management program. That program provides individually focused assessments and interventions in the patients' homes, as well as in their doctor's office, hospitals, skilled nursing facilities, and other community settings.

The program was one of 15 sites chosen by the Centers for Medicare and Medicaid Services (CMS) in 2002 to participate in the national Medicare Coordinated Care Demonstration, and is the only one of the 15 sites that continues to be funded. Based on the success of the demonstration program, Aetna contracted with HQP to develop a similar program for its high-risk Medicare Advantage members. The program designs are slightly different but both result in reduced hospitalizations and costs, according to Sherry Marcantonio, MSW, ACSW, senior vice president for Health Quality Partners.

Among higher risk patients in the Medicare demonstration program, hospitalizations dropped by 39% and emergency department visits by 37%. Medicare Part A and B medical expenditures were $6,132 per person, per year lower than those of a control group with similar diagnoses who received the usual care. Net savings to Medicare, after HQP's payment, totaled $4,764 per person per year. Participants were Medicare fee-for-service beneficiaries with a diagnosis of coronary heart disease, heart failure, or chronic obstructive pulmonary disease, and a hospitalization in the year prior.

In the first year of the Aetna program, hospitalizations were reduced by a relative 20% and medical costs were 18% lower when patients in the program were compared to members with similar conditions who did not participate.

In the current demonstration extension, CMS has identified a target group of people who have chronic obstructive pulmonary disorder, heart failure, diabetes, and/or coronary artery disease who have been hospitalized in the past year and who live in eastern Pennsylvania.

Aetna identified 942 members with one or more chronic conditions who were being treated by primary care providers with whom HQP was already working. In the first year, HQP identified and outreached to 200 of the 942 patients as being at highest risk.

When patients are identified for the program, HQP sends them an introductory letter explaining the program and alerting them that an HQP nurse care manager will be in touch. If they are interested in participating, the nurses meet them in their home, discuss the program in detail, and enroll them with their consent.

Building a rapport with the patient is a key factor in the success of the program, Marcantonio says. "In order to teach patients the skills they need to manage their own care, care managers need to spend time in person, develop relationships with them, and build trust. These patients have many unmet needs, issues, and concerns. We try to begin with what is the most important to them," she says.

The care managers use a multi-dimensional geriatric assessment and screening that may take as many as three visits initially to complete.

Reviewing medication is a major part of the care manager's job. "When we see the pill bottles in the home and compare them with a list from the hospital and the doctors, we typically find redundant medications. Every time we visit, we go over the list. These patients' conditions are so complex that the medication list often needs updating," she says.

Maryellen Keller, RN, BSN, director of care management, adds that on every visit, care managers get the patients to demonstrate step-by-step how they are taking their medication. If they aren't taking it, the care managers ask them why. "If patients can't afford their medications, the care managers help them sign up for programs to help them pay for the drugs. If they say they don't like the way the drugs make them feel, they work with the physician to modify or change the medications" says Keller, who also carries a patient caseload.

The care managers educate patients about their disease, how to prevent complications, and what to do when symptoms indicate an exacerbation that calls for early intervention. They teach patients how to read food labels, and establish action plans for losing weight, exercising, and weighing themselves.

The care managers conduct a physical assessment on each visit and report abnormal findings and new or worsening symptoms or problems to the patient's physician. They identify fall risks and social needs and work with community agencies to help them access additional services to help them remain in their homes.

For example, one of the care managers visited a patient recently discharged from the hospital and saw that she was unsteady on her feet, and that her husband was hard of hearing and couldn't hear her call for help. She helped them set up an emergency response system and followed up with the inpatient case managers and primary care physician to get home care physical therapy and occupational therapy set up. She arranged for a medical social worker to assess the couple's financial assets to determine if they were eligible for assistance programs.

The care managers build a relationship with the physician office staff and collaborate with the physicians around medical management, medicine reconciliation, and strategies for helping patients manage their conditions.

Marcantonio adds that the organization also provides best-in-class, structured, interactive group programs for weight loss, gait and balance training, self-management education and skill building for chronic diseases, and seated exercises.

Once patients are enrolled in the community-based care management program, they stay in the program until they move outside the area, or die. "One of the unique things about the role is that we have long-term relationships with patients, rather than providing episodic care," she says.


Person-centered care appeals to nurses

They like face-to-face contact

Care managers who work in Health Quality Partners' community case management program often tell Sherry Marcantonio, MSW, ACSW, senior vice president for the Doylestown, PA-based healthcare quality research and development organization, that working face-to-face with patients "is why I went into nursing."

"Our nurses love the opportunity to spend time with patients and family members and focus in a person-centered way. They tell me it's the best nursing job in the world," she says.

Nurses in the program have a minimum of 10 years of clinical experience but most have more than 20 years of clinical experience. Many have backgrounds in home care, hospice, oncology, or cardiac care.

The care managers go through intensive six- to nine-month training and have work space in the HQP headquarters, but they do most of their work in the community, coming to the office for meetings with supervisors and weekly team meetings.

Case managers are assigned by geographic area and carry a target caseload of 75 patients at a time. They spend most of their time in the community and use notebook and laptop computers for documentation and to access patient education videos, curriculum and patient education hand-outs.

The care managers provide an average of 13 home visits, per person, per year, see them in the doctor's office for two visits a year, and make follow-up phone calls to monitor progress between visits an average of 12 times a year, according to Marcantonio. "These patients have multiple chronic diseases and a lot of complicated care needs. Our care managers see them a number of times face-to-face," she says.

Maryellen Keller, RN, BSN, director of care management, reports that the frequency of the home visits and telephone contacts depends on the issues the patients are having, and changes according to the patient needs. "They always have us as a resource. Some nurses visit the patients once a week to fill their pill box. These are patients who can stay well if someone organizes their medication and reorders it when needed," she says.

To have a successful community case management program, case managers have to be flexible, be able to understand their patients' concerns, and work with them on their priorities, Keller says. "People who just want to tell people what to do won't be successful in this role. We have to be supportive and help our patients modify behaviors or overcome barriers to adherence," she says.

The case managers are creative in the way they approach people and try different ways to help them reach their goals, rather than being judgmental, she says. For example, if a patient needs to exercise, the care managers help them find something they enjoy doing that will help them become more active.

"We look for little things, like getting smokers to start quitting by cutting out one or two cigarettes a day, or encouraging patients who overuse alcohol to have one less drink a day," Keller says.