Published on : January 15, 2014
Bring Case Management into Local Communities to Improve Results
Health care reform and changing market dynamics are driving strong interest in engaging patients at the local level of care to improve outcomes and optimize cost savings. In response, case management companies are increasingly integrating their nurse case mangers into the local provider community.
For employers, employees and providers,that local presence can make a big difference. It helps employers stem the impact of high-cost claims, enables employees to navigate the complex health care system and assists providers in delivering improved care and reducing inappropriate hospital readmissions.
Chronic Care’s Toll
Case management has long focused on those employees – typically one to five percent of most employers’ populations - with chronic, high-cost conditions, such as heart disease, diabetes and cancer, as well as those with complicated pregnancies, trauma or other acute medical conditions.The human and financial toll of chronic illness in the U.S. is staggering. Individuals with multiple chronicconditions often suffer relapses and make repeat visits to hospitals, emergency rooms and health clinics.
Consuming such high volumes of health care servicesdrives up costs. According to the Centers for Disease Control and Prevention, approximately 133 million Americans – nearly one in two adults – live with at least one chronic illness. Chronic conditions account for more than 75 cents of every dollar spent on health care. The costliest one percent of patients account for over 21 percent of total U.S. health care expenditures, according to Kaiser Health News. Case management can play an important role in helping people manage their chronic conditions and containing costs.
Traditional Case Management
Traditionally, employer sponsored health plan case management has been delivered by trained nurse case managers who typically talk to patients by telephone, assisting them in obtaining long-term support following a hospitalization, catastrophic health event or complex diagnosis.
Nurse case managerseducate, empower and support patients’ post-hospitalization recovery process. They are charged with improving patients’ compliance with their treatment plan and ultimately, lowering employers’ medical spend by helping to:
- Reduce hospital readmissions
- Decrease inappropriate use of specialty care
- Decrease misuse of the emergency room
While this traditional model has helped achieve these goals for many years, we believe the full potential of case management has yet to be realized. And, the limiting factor may be simple logistics.
Since nurse case managers are not in the same physical location as patients, they typically facilitate case management services by telephone from remote call centers. Presence within the local care delivery system and the patient’s community may assistthe nurse’s ability to build synergies with the local care team and to more fully consider non-clinical aspects of a patient’s recovery when providing support.
Localizing Case Management
The challenge is how to improve the traditional phone-based model and deliver even better results for employers, providers and patients. We believe the answer lies in building stronger connectivity between case managers and the patient and the patient’s local care team.
Optum is putting this into practice by physically locating its nurse case managers in several areas throughout the United States which contain a significant volume of patients with chronic, high cost conditions. The goal is to improve case managers’ ability to provide support by working one-to-one with patients and to more closely integrate case management services with the local care team.
Maintaining a local presence enables our case managers to:
- Work closely with patients’ doctors and other providers to coordinate care and ensure that patients are following their treatment plan.
- Build a relationship with the patient by visiting them at home or in the hospital.
- In support of the patient’s treatment plan, design a personal plan that considers factors such as social support needs, mental health issues and financial circumstances that often have a profound impact on patients’ recovery.
The goal, simply, is to achieve positive health outcomes and reduce inappropriate utilization of health care resources.
Stationing case managers locally has already delivered benefits to employers. One example is Optum’s recently implemented pilot program with an integrated health delivery system with several thousand employees and dependents. The program focused on those with complex, chronic conditions such as coronary artery disease, diabetes and heart failure.
Optum’s locally based nurse case managers worked directly with patients who were non-compliant with their medical treatment plans. They facilitated access to community resources, provided education and addressed psychosocial needs. In essence, the case mangers filled the gap between the physicians’ treatment and patient’s ability to care for themselves.
The results of the pilot program included:
- Reduction in health care costs by 65 percent for high-cost patients
- Higher compliance with treatment plans resulting in improved outcomes and patient satisfaction with self-management strategies
Optum recently completed another pilot programwith a large hospital system with 32,000 employees and dependents. Optum nurse case managers were placed in local hospitals in an effort to closely manage patients identified as high risk for readmission following discharge from a hospital or skilled nursing facility.
The case mangers met in person at the hospitals with patients and their discharge planner to ensure continuity post-discharge. These face-to-face meetings helped build rapport and establish trust between patients and their case managers. Case managers then followed up either in person or by phone with the patient within a day of discharge toreviewmedications, ensure durable medical equipment was set up at homeand make follow-up appointments with the patients’ doctor within five days of discharge. The case managers continued following up with the patient for the next thirty days to help prevent a readmission.
As a result, nearly three quarters of patients engaged with case managers post-discharge, up from 45 percent before the program was implemented. Additionally, hospital readmission rates declined 37 percentwhere Optum deployed the readmission prevention program.
As the cost of chronic care continues to escalate, employers should consider implementing innovative strategies such as locally based case management.Managing those conditions effectively requires a combination of coordinated clinical care, increased engagement by patients in handling their own care, psychosocial support and lifestyle coaching — all on an ongoing basis. For employers, that mixture can yield decreased hospital readmission rates, faster return to work, improved productivity and lower medical costs.
About the Author
Hilary Lyon MBA, MPH, RN,is the Vice President of the Clinical Consulting team at Optum. Hilary has over 35 years’ experience in the health care industry. She provides clinical expertise and consultation to Optum’s national and international clients across all markets. She obtained her Masters in Public Health from the University of Texas, an MBA from the University of Houston and a registered nursing degree from the University of London.