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Bedside interventions reduce admissions, stays
Plan targets disabled SSI members
As a result of case management interventions at the hospital bedside, emergency department (ED) visits, hospital admissions, and net days in the hospital have dropped dramatically for the Social Security Disability Insurance (SSI) population served by Horizon/Mercy.
The health plan, a program of Horizon Blue Cross Blue Shield of New Jersey, is New Jersey's largest managed health care organization serving the publicly insured in all 21 New Jersey counties. The company has headquarters in West Trenton.
The program was aimed at members who typically use the ED and hospital as their medical home, rather than using a primary care physician or choosing a specialist as a primary care physician.
"They were not receiving their durable medical equipment or having their prescriptions filled at the pharmacy, and they often ended up in the emergency room. Most people with chronic disease and disabilities who come to the emergency room usually can be admitted for at least 24 hours," says Pamela Persichilli, RNC, director of utilization management for Horizon/Mercy.
The project was designated a Best Clinical and Administrative Practice by the Center for Health Care Strategies, a Lawrenceville, NJ, organization that promotes high-quality health care strategies for low income people.
To calculate return on investment, the health plan reviews the medical history of the people who were visited by the case managers to see their resource utilization before the bedside intervention, and then compares it to utilization after the intervention.
The health plan monitored 536 members who received bedside interventions and maintained consecutive enrollment for six months before and six months after the program began.
In the first six months, ED utilization decreased by 20.11% among the 536 members who received bedside interventions, compared with the six months before the program began.
There was a 17.52% decrease in net admissions per 1,000 members and a 7.09% decrease in net days per 1,000 members among the same population.
At the same time, there was a 31% increase in members who were treated by a primary care physician and a 3% increase in members treated by a specialist; home health services increased by 336%; pharmacy costs increased by 7%.
After the program started, the successful social work interventions went from a rate of about 30% to 40%-60% or above. The definition of a successful intervention is that the social worker found the member and spoke to them.
Before beginning the program, Horizon/Mercy examined claims and case management data and identified the top 20% of its SSI population that was utilizing the hospital ED for care instead of visiting a physician.
The program started out with the SSI population and state-funded General Assistance beneficiaries, mostly adult men eligible for Medicaid. Halfway through the project, the state removed the General Assistance members from the Hori-zon-Mercy population.
"At that time, we examined the preliminary data to determine if it was worth it to continue. The initial data demonstrated the impact of changing members from an inpatient and emergency room model to a primary care physician and specialist model," Persichilli says.
The members targeted by the program are a challenge to locate. Few members have telephones. Some change addresses frequently and many have a fear of home visits. If a social worker attempts to visit them, the family members may be afraid to open the door to a stranger.
"The members are only slightly above the poverty level. Many are homeless. It's a significant challenge to do any case management or to be able to impact their health needs when we cannot find them," says Philip Bonaparte, MD, chief medical officer.
Instead of going on home visits and searching for them in the community, the Horizon-Mercy staff decided to visit the chronically ill members in the hospital.
"We're working with the member at their most vulnerable time, a time when they are in the hospital and they see firsthand what the impact can be of not following their plan of care. The case management social workers are helping them right then and there, and they are starting to build a trusting relationship," Bonaparte says.
The hospitals notify Horizon-Mercy within 24 hours of any member's admission.
"This notification has nothing to do with approving or denying care. We have a program status code that identifies what plan the member is enrolled in. It is a tickler for the social work case manager to know who she needs to visit in the hospital that day," Persichilli says.
The social worker case manager visits the members at the bedside with a cell phone and helps the member locate his or her primary care physician on the spot.
"The social work case manager can help eliminate some barriers for care. They can change the primary care physician to someone familiar to the member, or at least, in their neighborhood," Persichilli says.
They set up appointment with specialists if it's indicated and call the Horizon-Mercy case managers to introduce them to the member.
"These are some of the simplest things to do to change the behavior of our members, and it goes a long way toward increasing satisfaction," she says.
The social worker case managers help introduce families to various community services and programs, such as food stamps, housing, and assistance with utility bills, and link them with other help available through community support organizations. They identify people with a behavioral health or addiction issue who need to be plugged into support in those areas.
When the program started in November 2001, the social workers performed a 30-question assessment.
"They learned a lesson that these were far too many questions to ask at such a time," Persichilli says.
The questionnaire has since been pared down to 10 questions, which gives the health plan the information it needs but doesn't tire out the patients.