Plan provides patients with referrals, home care

Demonstration project aims to reduce hospitalization

A Medicare demonstration project at Montefiore Medical Center in New York City provides care coordination to help high-cost, fee-for-service beneficiaries comply with their medical treatment plan and access the community services they need to manage their chronic conditions.

"We are leveraging the experience we have in a managed care environment and applying it to a fee-for-service, high-cost population. We are using some of the principles of case management that are used in managed care and applying them in a non-managed care environment while working directly with patients, providers, and caregivers," says Ann Meara, RN, MBA, associate vice president, network care management.

Part of CMS demonstration project

Montefiore Medical Center, the largest health care provider in the Bronx, is one of six health care providers chosen by Centers for Medicaid & Medicare Services (CMS) for a three-year demonstration project showing how care coordination, assistance with social support, and monitoring of patient's medical conditions can help prevent complications from illness and reduce emergency room visits and hospitalizations.

CMS has identified chronically ill Medicare beneficiaries who live in 16 designated zip codes in the Bronx and meet the criteria for the Care Guidance care coordination program. Participants in the program are all fee-for-service Medicare beneficiaries. If they join a Medicare Advantage or other plan, they are automatically withdrawn from the program.

"All of the participants have had some contact with the Montefiore system. It may be as minimal as having blood drawn here but CMS did include a loyalty criteria in the selection process," Meara says.

Each Medicare beneficiary who agrees to participate is assigned a care coordination team, depending on where they live and what their primary language is. The teams, led by a nurse case manager, include outreach specialists, patient educators, and social workers.

The care management team works with patients to understand the challenges they face in complying with the medical treatment plan. They identify social issues and other challenges that may hinder patients from fully complying with their treatment plan and work with them to overcome the challenges.

"This is not a disease management program. It is a program that deals with those issues that interfere with a patient's ability to adhere to a treatment program. We are providing caregivers with the resources they need to take care of the patients and help them stay healthy," she says.

For instance, the teams have found more appropriate housing for some participants whose living arrangements had been contributing to their frequent hospitalizations. They may arrange transportation for medical visits or connect participants with community services, such as Meals on Wheels.

Life planning is one of the biggest issues that the team addresses with the participants, Meara says.

"We talk a lot to the patient and family members about health care proxies and advance directives and the importance of having these documents in place," she says.

Many of the participants don't understand their medication regimens and the case managers work to educate them. They educate the participants about their conditions and about lifestyle changes they can make, such as exercising or good nutrition, to help keep them under control.

They refer people who are at risk for falls to the hospital's falls risk prevention program.

"The case managers make a lot of referrals for conditions that have not gotten attention. For instance, we have identified a network of dentists in the community who will treat Medicare beneficiaries and who have arrangements that base payments on a sliding scale that is tied to income," she says.

When the program was initiated, the medical center hired a temporary outreach team of community members with previous customer service experience and trained them on the program and how to communicate with the beneficiaries. Some of them are peers to the people they are calling.

After the initial group was enrolled, the medical center hired three members of the outreach team to continue enrolling participants.

When a participant enrolls in the program, a case manager calls him or her on the telephone and conducts an extensive assessment that covers nine domains, including: cognitive capacity, level of function, risk of falls, medical condition, end-of-life planning, and previous medical history, she says.

The information is collected in an electronic system, which stratifies the participants based on their psychosocial and medical needs and how much intervention they are willing to accept. One group of beneficiaries is self-directed. They were willing to participate but didn't want to complete an extensive assessment.

The care coordination team uses the electronic system to generate a problem list and develops an individual care plan for each member. The nurse team leader reviews the plan with the team, and depending on the participant's needs, assigns the person to a member of the team. For instance, if a participant needs help scheduling an appointment, that task is assigned to a non-clinician.

The teams are supported by a full-time pharmacist, a full-time nutritionist, a geriatric psychiatrist, and an internist. For instance, if there is a polypharmacy issue, the pharmacist calls the patient or caregiver and reviews the medications.

Follow-up calls are made according to the stratification level of the participant.

The Care Guidance program began a telemonitoring initiative for patients with heart failure in late 2007. Participants who meet certain criteria for congestive heart failure receive a scale with a monitoring device that connects to their telephone. They weigh themselves each day and answer a set of questions that they transmit into an electronic system that notifies the care coordinator if the patient appears to be having problems.

The case management interventions are primarily telephonic. The nurses may go to the home if the participant is uncomfortable doing the assessment over the phone, if he or she is hard of hearing, or if the primary caregiver prefers to be present.

Home assistance

Home-bound patients who are not receiving regular medical care from a primary care physician are referred to the medical center's Medical House Calls program, a team of physicians and nurse practitioners who provide care to patients in their home.

The team gets a hospital census every day to identify anyone in the program who has been admitted to Montefiore. If someone is hospitalized, the team's physician visits them in the hospital, assesses the condition, and makes a determination about appropriate follow up.

"This program is under our network care management program. The nurses who are conducting the telephonic case management work with the nurses at the hospital who are involved in utilization management and care management," Meara says.

The Care Guidance team coordinates care with the utilization nurses and case managers in the hospital and with the treatment teams throughout the health care system. Everyone in the health system has access to the same clinical information system and can share information.

"One of the things we've tried to do is to integrate what we do when people are outside the hospital with what we do when they are in the hospital," she says.