Case management for uninsured cuts length of stay, readmissions

Patients are encouraged to have a primary care home

Faced with a growing number of uninsured patients and rapidly escalating costs for treating them, Brackenridge Hospital in Austin, TX, created a case management program for the uninsured that has resulted in shorter lengths of stays (LOS), fewer readmissions, and less utilization of the emergency department (ED) by patients being managed.

Brackenridge Hospital provides the majority of indigent care for Seton Healthcare Network, a not-for-profit organization that provides services in an 11-county area of Central Texas. The cost of providing care for the medically indigent was about $100 million in 2003.

The health system came up with two strategies to combat the problem: aggressive medical management to decrease LOS once patients are admitted and the case management piece to help manage the care of the uninsured to avoid hospitalizations and ED visits, says Gary Piefer, MD, medical director for Seton Regional Health Services.

"The cost of care for this population rose from $50 million to $100 million in just three years. The initiatives slow down the increases. Costs are still going up, but the cost per case for the cases we are managing is decreasing," he explains.

The hospital started an outpatient case management program for uninsured frequent users of the hospital services in 2002 with just one case manager. Now there are three case managers, with plans to hire two more, says Rebecca Cook, LMSW, outpatient case manager supervisor.

Case managers at Brackenridge Hospital manage the care of its uninsured high utilizers in the same way that a disease management case manager or an insurance company case manager would. "When we get a referral, we look up their medical history to get as much background as we can. We get in touch with them by telephone to let them know about the program and set up a time to meet them face-to-face," she says.

The case managers do an extensive assessment, including a psychosocial history, and work with the patient to set goals they will work on together.

They educate patients about their conditions, encourage them to see a primary care physician rather than going to the ED, make sure their have their prescribed medications, and encourage them to follow the treatment plan.

"We really start with the basics, like making physician appointments and keeping them. These are people who have fallen through the cracks. The regular system has failed them, and they’re kind of lost," Cook notes.

They help patients who are high utilizers of the ED find a medical home, usually one of three clinics operated by Seton that provide primary care services for the uninsured.

Since the program began, LOS has gotten shorter and there are fewer readmissions. Some patients still utilize the ED for primary care, but the utilization has gone down. The per-patient per-month pharmacy costs have dropped from about $20 to about $5 among the case managed population, Piefer says.

The health system measures total bed days per quarter and patients coming in with multiple admissions. "There is a percentage of patients you can’t do anything with. If you accept that and move on, there’s a large group of patients you can do a lot for," he says.

The health system began by looking at the uninsured population as if it were a payer group and manages the care accordingly. It looks at who are the frequent utilizers of care, who has had repeat hospitalizations, and which patients have complex diseases and comorbidities, Piefer points out. It created a list of patients who were uninsured who had three or more hospital admissions in 12 months or six or more ED visits in the past 12 months. "We created a list larger than anyone had anticipated," he adds.

For the initial complex case management program, the health system picked the patients who were at greatest risk for utilization and those whose care had a high dollar cost and began a pilot program with one case manager assigned to a group of 35 to 50 patients. The three case managers together handle a load of about 100 active cases, Cook notes. "I’ve been working with some of these patients since the program began. Others I’ve work with for about a month and closed the case," she adds.

The case managers meet with Piefer, another medical director, and the case management director once a week to review complicated patients.

"Case management is what has been missing in care of the uninsured," he says. "If a patient is in the hospital and the only reason he couldn’t go home was that he couldn’t get a walker or his electricity was turned off, the case manager brings that to the meeting. We weigh the cost of keeping them here five days or spending less money to help get them out of the hospital."

Many of the patients don’t realize they have a treatment plan, Piefer points out. For instance, many patients with congestive heart failure don’t know they need to monitor their weight and see a physician frequently.

They make sure patients are getting their medication, they are getting outpatient physician follow up, and, if there is a change in status, that they call the case manager before they go to the ED. "Most of the visits to the emergency room are not emergencies. These people were using the emergency room as primary care access," Piefer adds.

For instance, the case managers may educate an asthmatic patient about his asthma medication, show him how to use an asthma inhaler, and help him learn what triggers an asthma attack, helping avoid a trip to the ED. "Unfunded patients don’t want to be in the emergency room, and they don’t want to be in the hospital. The case managers help them avoid both," he notes.

One subset of patients has chronic diseases as well as significant mental health problems that impact their disease. When their anxiety level goes up or they don’t comply with their treatment because of depression, they often go to the ED.

"The case managers serve as health care concierges. They encourage the patient to call them before they come into the emergency room," he points out.

When a patient calls the case manager, he or she determines what is going on and suggests appropriate steps to take. If the patient already has called his or her primary care provider and can’t get an appointment for a few days, the case manager will call and expedite getting the patient in that day.

"The case managers have me and two other medical directors to help them remove the barriers at the clinics and physician offices," Piefer says.

Since many of the uninsured don’t have telephones, the hospital put in a toll-free number so the patients could call the case manager from any telephone. "We’ve been able to establish contact with everyone so we can do follow-up," he adds.

The health system creates outcomes reports for the patients’ primary care physicians, showing them the ED utilization for their patient panel.

"The physicians were not aware that when the patients couldn’t get an appointment with them they were going to the emergency room," he says.

Many of the patients who are initially in the case management program qualify for Medicaid or another funding source but don’t know it.

"When you have a three-day length of stay, by the time we determine the patient qualifies for a funding source, he’s gone," Piefer notes.

The case managers at the hospital work with those at the clinics to help members become eligible for funding sources and help them identify other funding possibilities, such as for prescription drugs.

"If we can help the patients manage their prescription drugs, they have a greater likelihood of avoiding hospitalization," he says.

The clinics work with pharmaceutical manufacturers to get free medications for the patients.

"The forms are long and complicated, and the patients don’t know where to get them. We have a system through our pharmacy that can fill out the forms and get the patients their medication," Piefer says.