Providing New Solutions for Care Coordination
Case managers are in a unique position in today's health care environment. The
rising costs of health care, combined with longer lifespans and corresponding
increases in chronic illness, have led to an increasing focus on the benefits
of care management and the development of new, innovative types of care management
programs both in the hospital and across the continuum of care. Although these
emerging programs vary in design and function, they share the common goals of
providing quality patient care and reducing health care costs.1 These new programs
also share the common theme of aggressively using information to create a collaborative,
inter-disciplinary approach to managing patients.
In a recent research paper for the Health Care Financing Administration (now known as Centers for Medicare and Medicaid Services), Mathematica Policy Research defined coordinated care programs as the following:
"Coordinated care programs should serve chronically ill persons 'at risk' for adverse outcomes and expensive care. They should remedy the known shortcomings in health care by (1) identifying those medical, functional, social, and emotional needs that increase their risk of adverse health events; (2) addressing those needs through education in self-care, optimization of medical treatment, and integration of care fragmented by setting or provider; and (3) monitoring patients for progress and early signs of problems. These approaches may be able to raise the quality of health care, improve health outcomes, prevent costly hospitalizations and other medical care, and produce program savings." 2
In today's fragmented health care market, care managers often possess the most comprehensive view of the patient including medical, psychosocial, and economic information of prime importance to patient care coordination and management. As patients move from one provider to another and from one health care setting to another, little communication and information is typically shared. For the health care team to work together in an integrated and coordinated fashion, care management programs have been developed to ensure effective communication and appropriate care across the health care continuum.
In order to do this effectively, case managers leading these programs need access to information systems to track the patient and communicate their recommendations to the right people or resources at the right time to avoid unnecessary, costly delays in patient care.3 Despite the value of their role, they have like everyone else struggled with assuring continuity of care in the burdened medical environment, and have not always been successful in proving their value with meaningful data.
The following two case studies look at structured care management programs that have been developed by West Virginia University Hospitals and Georgetown University Medical Center. Although these programs share common definitions of care coordination and care management, the scope and goals of the program are significantly different. However, common theses exist for both programs that will help other organizations to create the right care management program for their community and patient populations.
West Virginia University Hospital
System-Wide Care Management Program
West Virginia University Hospitals (WVU Hospitals) has created a system-wide care management program that encompasses utilization management, case management, discharge management, and denial management. WVU Hospitals' focus is to improve the quality and cost-effectiveness provided to all patients seen at the Hospital and to improve the coordination of care for patients as they move throughout their continuum of care.
In establishing their program and processes, WVU Hospitals worked with Cap Gemini Ernst & Young to redesign their program and the staff's roles and responsibilities. During the redesign process, senior management, physicians and care management professionals worked together to define the optimal care management processes that would ensure that patients were managed effectively.
After the redesign, the care management program was transformed into an inter-disciplinary team approach to completing reviews, assessing and managing patients, and implementing treatment and discharge plans. As part of this process, WVU Hospitals established a resource center staffed with payor specialists, registered nurses, a social worker, and staff assistants. Using a care management information tool developed by Canopy Systems, Inc.TM, the resource center handles many of the daily administrative tasks of care management, which allows the clinical care coordinators and social workers throughout the hospital to focus on working with the patients, families, and physicians in order to optimize the care delivered.
The payor specialist in the resource center receives an alert when a utilization review is completed on the floor and then communicates the review to the payor in order to obtain authorization for payment. If a retrospective denial comes in, the payor specialist documents the denial, which initiates the appeal process. All of the communication, documentation, and coordination are handled in Canopy's care management system.
The clinical care coordinators and social workers also send tasks to the resource center to help them secure appropriate post-acute services for their patients. This process includes finding appropriate skilled nursing beds, home health services, and durable medical equipment. By creating this centralized resource center for care management, WVU Hospitals has improved their case and discharge management process, reduced denials, and improved employee satisfaction.
WVU Hospitals also implemented a process for the clinical care coordinators to concurrently collect process and outcomes measures as they are managing the patient. The clinical care coordinators receive an alert when a patient is on a clinical practice guideline, which prompts the clinical care coordinator to monitor and document the patient's attainment of specific outcome measures in Canopy. These alerts can also serve as reminders to provide certain services or patient education before the patient moves to the next level of care.
By developing an inter-disciplinary approach, improving communications, standardizing processes, and implementing an information tool, WVU Hospitals has successfully created a care management program that is improving quality of care and providing a financial return for the organization.
Figure 1: Mind My Heart incorporates high touch with high tech.
Georgetown University Medical Center
Mind My Heart
Georgetown University Medical Center is participating in the Medicare Care Coordination Demonstration project and has created a program called Mind My Heart. Mind My Heart is a coordinated care management program for the congestive heart failure population and is available to any person in the DC metro area over the age of 65, with a diagnosis of Congestive Heart Failure, who is enrolled in Medicare Parts A & B and has been hospitalized in the past year. Patients who are selected and who agree (along with their physicians) to participate in this randomized study will receive all coordinated care services included in the program.
As part of the Medicare Demonstration Project, Mind My Heart is evaluating the benefits of community-wide care management to a targeted population. The program is built on the premise that by managing and monitoring CHF patients at home, the patient's quality of life will improve; the quality of care delivered will increase; and the overall health care costs will decrease. Overall, the program is evaluating and expecting the following outcomes:
- Reduced health care costs
- Decreased hospitalizations, ER visits, and readmissions
- Reduced length of stays when the patient is hospitalized
- Improved patient and physician satisfaction
- Increased patient perceived quality of life
- Adherence to medical best practices
- Effectiveness of care management technology
Mind My Heart believes in a care management model that encompasses community-wide case management and disease management. A patient is assigned to a Registered Nurse Care Manager (CM) who is available to the patient 24 hours a day, 7 days a week, and who monitors patient vitals on a daily basis. The CM visits the patient in his home or by telephone to make sure things are going well and to teach the patient about CHF, medicines, and diet.
Helping with the process is a home monitoring device developed by HomMed LLC, which automatically takes the patient's weight, blood pressure, pulse, and other vital signs. The machine talks the patient through this process each day, and then electronically sends the results to the Canopy Systems care management solution used by the care managers. Based on the information collected each day, the care managers could receive an alert that the patient needs to be seen or called.
The care managers are continuously reviewing and monitoring results, talking to the patient's physician, and helping to ensure that all is going according to plan. The care managers call on the program's multi-disciplinary team (pharmacist, nutritionist, social worker, and medical director) for further advice and suggestions. The care managers do not provide hands-on home care services but instead work closely with the home care nurse when needed.
Patients in financial need can receive some additional help with purchasing of medications for their CHF as well as transportation vouchers to use for doctor appointments, clinic visits, etc. Patients keep their current physician(s) and hospital(s) of choice.
Although Georgetown is just beginning to work with CMS to evaluate the results of Mind My Heart compared to the control group, they have already been successful in establishing a collaborative approach for improving care coordination. If the success at Georgetown and other demonstration sites continues, this may result in a new type of service covered by Medicare.
Figure 2: Care Management
Summary
WVU Hospitals and Georgetown University Medical Center have successfully implemented innovative care management programs that improve care and reduce costs. Although these programs vary in scope and design, they share a number of common themes and important implications that should be studied by other organizations that are evaluating their own programs:
- Create a collaborative approach between care managers and physicians. Both organizations worked together with their physicians to develop and implement the new care management program.
- Standardize care management processes whenever possible and monitor the success of these processes. WVU and Georgetown use information tools to guide care managers through assessments, reviews, and plans of care and continuously evaluate the outcomes of their program.
- Create an information repository that all members of the care team can access appropriately. Sharing information and alerting team members of their role in the treatment plan allows both programs to be successful.
- Develop strong communication between the care management team and the patient. A critical success factor for all care management programs is effective communication. Both organizations developed standard communication protocols in the design of their new programs.
- Allow care managers to spend more time working with the patient, physician, and family and less time on the phone or the fax machine. In order to be successful, care management involves a lot of paperwork, documentation, and communication to outside organizations. Using information technology, both of these programs are reducing the care managers' administrative work.
- Monitor outcomes and be willing to change processes along the way in order to maximize success. There is not a standard plan or process that works for all organizations or patient populations. Both WVU Hospitals and Georgetown are constantly evaluating their programs and looking for ways to improve the care being delivered.
