CM program keeps high utilizers out of hospital
CM program keeps high utilizers out of hospital
Focus is on psychosocial and medical needs
A care management program that concentrates on high-cost and high-utilizing patients with complex medical and psychosocial needs has reduced the overall readmission rate at the University of Michigan Hospitals and Health Centers to 17.4%, down from 20% when the initiative began.
A team of nurse care managers, social work care managers, and non-clinical patient care associates monitors the inpatient discharges and emergency department visits of all patients covered by Medicare, Medicaid Managed Care, and uninsured patients, which includes people covered by the county insurance program, according to Brent Williams, MD, MPH, medical director of complex care management at the University of Michigan Ann Arbor Medical Center.
The patient care associates call the less acute patients after discharge to make sure they understand their discharge instructions, have a follow-up appointment with their physician, and have filled their prescriptions. They screen for any potential problems and refer complicated or challenging patients to a care manager.
The care managers assess and provide brief follow-up for low-complexity patients at discharge and provide ongoing intensive care management for patients with complex medical and psychosocial needs. Each care manager typically provides intensive care management for about 25 to 35 patients at a time. The program concentrates on patients who are under 65 but are high utilizers of the emergency department and hospital, Williams says. Many of these patients have complex comorbidities and mental health or substance abuse issues. Many are homeless or have little social support.
Patients who qualify for the intensive care management program have impairments in at least three of the following domains: major psychiatric issues; behavior health issues, including personality disorders and substance abuse; complex medical conditions; diminished social support system; limited physical resources, including financial issues, poor living conditions, lack of transportation, and lack of healthcare coverage; and functional deficits.
When patients are identified for the program, the care manager initially contacts the patient by telephone and completes an assessment of the patient's condition and needs, then begins to fill in the gaps. In addition to medical issues, the assessment determines what the patients understand about their diseases, if they understand their medications and how and when to take them, if they have transportation to the pharmacy, and if they can afford their medication. The care managers find out if the patient has a primary care physician, if he or she has an appointment, and has transportation.
The care managers coordinate all of the patients' care needs, including getting them enrolled in home health if appropriate, coordinating care with any specialists, and facilitating transportation. If the patient is homeless, the care manager works with the case manager at the homeless shelter to get the patient a bed.
The care managers often accompany patients on visits to their primary care physician, and often can provide the physicians with information about the patients' social circumstances or financial issues that the physicians wouldn't otherwise know. "This creates a strong relationship between the care manager and the primary care physician. They meet with the patient and the three of them work together to develop a care management plan," he says.
Physicians traditionally base their treatment plan on the patient's disease and may be challenged by patients who have psychosocial needs. "The care managers can provide important education and help meet the patient's non-medical needs," he says.
Traditional disease management models assume that patients are motivated to change and have the resources available to them to help them manage their condition, Williams points out.
"This is not true for many patients who are in and out of the hospital frequently. What we do seems to make more difference than the traditional disease management programs," he says.
The care managers' computer program alerts them each day if patients in the program are in the hospital or have been to the emergency department. The care managers then visit the admitted patients in the hospital and work with the nurse care manager and the physician on the discharge plan. They follow up with patients who have been to the emergency department by telephone.
The hospital has organized twice-monthly meetings of care managers from throughout the Ann Arbor area. Participants include care managers from the University of Michigan Hospitals and Clinics, their counterparts at St. Joseph Mercy Health System, also headquartered in Ann Arbor, and care managers from the county health insurance plan, the local homeless shelter, a substance abuse program, and the county mental health department.
At the meetings, participants brainstorm on ways to coordinate care for vulnerable and under-served patients. "They get to know each other on a personal basis, and understand what the other participants in their organizations need as patients transition. This has facilitated a good working relationship and they often pick up the telephone or send an email to discuss problem cases," he says.
Source
For more information contact:
- Brent Williams, MD, MPH, Medical Director of Complex Care Management, University of Michigan Ann Arbor Medical Center email: [email protected].
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