Plan’s case managers visit clients face-to-face
Plan’s case managers visit clients face-to-face
Proactive approach aimed at preventing problems
Case managers at Health Plan of Nevada interact face-to-face with their clients to coordinate their care, working with them in physician offices, specialty clinics, hospitals, and the patients’ home when necessary.
"We go to the patients and work with them proactively. We try to avoid train wrecks by seeing the patient in time to prevent problems," says Dana Zuckerman, RN, BSN, MA, assistant vice president for utilization and case management for the Las Vegas-based health plan, a subsidiary of Sierra Health Services.
The health plan has on-site case managers at all of the greater Las Vegas area’s 11 hospitals. They work with the hospital team, act as a liaison between the hospital and the patient’s primary care physician, and work with the health plan’s social workers to take care of discharge needs in a timely manner.
The hospital case management team visits and interviews every member who is hospitalized.
"We may not follow up ourselves because most of the patients are in the hospital only three to five days, but we do set the wheels in motion," says Ellen Aliberti, CCM, director of continuity of care for Health Plan of Nevada.
Interdisciplinary team
Case managers are a part of the interdisciplinary team at each of the primary care clinics operated by Southwest Medical Associates, a multispecialty medical group owned by Sierra Health. About 70% of Health Plan of Nevada’s members select Southwest Medical Associates as their primary care provider.
Members who have other primary care providers are followed by case managers who may see patients in their home or accompany them on visits to the physician.
Case managers who cover a rural area often travel to patients’ homes for assessments, accompanied by a social worker when the member needs social services.
"Any member can have a case manager if a need arises or if their provider feels that it would be helpful," says Sandra Blake, RN, clinical director for Southwest Medical Associates.
The treatment teams at all locations, including Sierra Health’s home health agency and skilled nursing facility, are linked by The Q, an electronic medical records and case management system that facilitates sharing of information between sites.
"Within the last few years, we’ve made a substantial investment in technology, including an electronic medical record that includes X-rays and other scans, and electronic prescribing, all with the objective of improving patient care and making sharing of information quick and comprehensive," Zuckerman points out.
The interdisciplinary teams at Southwest Medical Associates include RN case managers, a pharmacist, a social worker, a health educator, physicians, physicians extenders, and support staff.
"These are all part of the team that takes care of the patient when he or she comes in the door. The teams are dedicated to preventative medicine. We want to catch things before they happen, rather than taking care of them after the member ends up in the hospital," Blake says.
The quality improvement department has helped the case managers use the health plan’s HEDIS measures to develop a registry of patients who have been diagnosed with certain conditions but who haven’t received the recommended care.
For instance, each primary care physician receives a list of patients with diabetes who have chosen him or her as their primary care physician.
The case managers check to make sure the patients have had the recommended tests and either send them a letter or call them to urge them to get the tests. If the patients have been assigned to the physician but haven’t visited the office in the past two years, the case managers contact them as well.
"We have a chronic care task force that is developing criteria so we can identify patients who may be at risk and start working with them before they fall into a higher category of risk," Blake says.
Specialty clinics
Southwest Medical Associates operates several specialty clinics where patients who meet criteria receive specialty case management along with their treatment.
For instance, the case managers at the heart failure clinic and chronic obstructive pulmonary disease (COPD) clinic take over from the primary care team, teaching the patients about their medications and helping them become compliant with their treatment plan. The team at the diabetes clinic, for patients whose diabetes is not in control, includes an endocrinologist and a certified diabetes educator.
The case managers at Southwest Medical Associates administer an annual health risk screening to members of Senior Dimensions, Health Plan of Nevada’s Medicare Advantage plan. They conduct the assessments either over the telephone or when the members come into the clinic and then use the information to develop a plan of care.
"We want to ensure that our members have the best quality of life and prevent hospitalization. We can’t always improve the health of our senior members, but we can help them maintain their health as much as possible," Blake says.
The questionnaire asks the members questions about how they feel, if they think they’re worse off now than last year, and what they think is wrong with them.
"People often have a different opinion of what is wrong with them, and it’s useful for the case manager to know what members think is going on with their health," Blake says.
For instance, patients with congestive heart failure (CHF) may think that they no longer have the condition when they aren’t having any symptoms.
"We do the health risk assessment every year. Sometimes a patient gets debilitated over time, and other times we find out through our assessment that we have been able to have a positive impact on their condition," Blake says.
Social HMO
The health plan implemented a Social HMO (SHMO) in 1996 with the aim of keeping the Senior Dimension member population healthy with the best possible quality of life by offering extended care benefits that would allow members to stay at home safely rather than going to an assisted living center or nursing home.
The health plan’s physical therapists conduct a complete safety evaluation of members’ homes to determine what is needed to keep the member safe. The plan may provide equipment, such as grab bars in the shower, assistance with activities of daily living or light housekeeping and, if necessary, equip the senior with an emergency system that allows them to push a button if they need emergency care.
The program provides respite care, adult day care, and social workers who help members in identifying financial resources, such as community agencies or drug companies that will provide free or discounted medicine for low-income people.
"We take a really comprehensive look at our frail elderly population, providing benefits that can keep them healthier and happier in their own homes," Blake says.
The program offers short-term benefits, depending on the patient needs. The social workers help them find community resources if long-term assistance is needed.
"This program has helped our elderly population become more compliant, and has helped prevent hospitalization and deterioration," Blake says.
Assessment and referral
Candidates for the SHMO are identified through the Senior Dimensions health screening assessment, by referrals from providers, self-referrals, or telephone calls from friends.
Patients who are part of the SHMO Program may be referred to the falls and mobility clinic for evaluation and if they need a special walker, wheelchair, or scooter, or to the Center for Senior Health, a treatment center for geriatric patients rated moderate to high needs and comorbidities who are treated by a geriatric team instead of a primary care physician.
The plan’s case managers who work in the hospital setting coordinate the care for between 400 and 430 patients in 11 hospitals every day, Aliberti reports.
"The hospitals welcome us. The patients are flying in and out, and they look on us as additional support to help with discharge planning," she says.
The hospital interdisciplinary teams include the case manager, social worker, and hospitalist. They round together every morning, discussing the patients who need more care, identifying those ready for discharge, and those who will need social work intervention.
When they visit the patient for assessment, Health Plan of Nevada’s case managers make sure that the patient has been assigned to a primary care physician and get in touch with the physician so the care will continue to be coordinated after the patient is discharged. They identify barriers for discharge and issues for the primary care case managers to follow up on.
Discharge summaries
The hospital-based case managers perform an integral role in alerting primary care physicians when their patients are in the hospital and making sure the physician has information about the hospital stay. They obtain all discharge summaries for the patients who are hospitalized and scan them into the electronic medical record so the physicians will have them available before the patient comes to the office for follow-up.
This enables the physician to view the case and learn why the patient was admitted and whether he or she was discharged to home with home health, transferred to a skilled nursing facility, or referred to a specialist.
"The hospital-based team model includes hospitalists in all the facilities. The patient goes back to the primary care physician, who has been advised of the patient’s hospitalization and has received the discharge summary. Through this system, we can end some of the siloing that occurs with managed care," Aliberti says.
Patient care coordinators
The hospital case management team is assisted by patient care coordinators who handle the paperwork for admissions, discharge, schedule follow-up appointments with the primary care physician, and do administrative work, such as faxing or preparing referrals.
"Sierra Health puts a real value on the nurses. We don’t have to spend a lot of our time on paperwork or faxing," Aliberti says.
Case managers are assigned to a specific hospital for continuity in care and are assisted by social workers who cover all 11 hospitals.
Aliberti’s department has four offices, located strategically throughout the city, so the case managers don’t have a long drive from the hospital they cover to the office.
Each site has an interdisciplinary team that meets regularly to coordinate care for the members.
The teams can pull in participants from other teams, if necessary.
For instance, if a patient has been in the hospital, the primary care team may pull in the case manager or social worker or a family member to the interdisciplinary team meeting.
"When an outlier patient enters the hospital, we call an interdisciplinary team meeting so we can give the primary care team a heads up," says Aliberti.
Access center
The health plan’s access center provides telephone advice 24 hours a day, seven days a week, assistance with transportation when the case managers are not on duty, and assistance with admissions.
The access center case managers answer the members’ questions and concerns, triage the cases, and notify other case management teams for follow-up if needed.
"Everyone who answers the telephone is an RN. They do more than just give advice on the symptoms the caller mentions. They take a more holistic approach to answering the questions and find out as much as they can about the caller, referring cases to other case management teams," Zuckerman says.
They provide discharge planning help and care coordination when the clinic and hospital-based case managers are not available.
For instance, if a member is in the emergency department but does not meet criteria for a hospital admission, the access center nurses may help coordinate an admission to a skilled nursing facility, set up home health services, or make sure the patient has a follow up appointment with a physician.
"They work with the medical director and act as a liaison to get the patient admitted to the right level of care," Zuckerman says.
Case managers at Health Plan of Nevada interact face-to-face with their clients to coordinate their care, working with them in physician offices, specialty clinics, hospitals, and the patients home when necessary.Subscribe Now for Access
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