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(Editor’s note: Lisa M. Zerull, MSN, RN, is the program director for case management at Valley Health System in Winchester, VA. Nationally recognized for her innovative work in developing Winchester Medical System’s community-based case management program, Ms. Zerull will be a featured speaker at next month’s Hospital Case Management Conference in Atlanta. This month, she shares with Hospital Case Management readers the basics of her "outside the walls" approach to patient care.)
Q: How did case management develop at Winchester Medical Center?
A: We’ve had acute care-based case management since 1988 or 1989. Around 1992, our acute care case managers began to identify what we call "frequent fliers." These were folks with diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, or depression, for instance, who kept coming back again and again through the revolving door into acute care. Our emergency department also had quite a few "revolving door" patients and were looking for a better way to manage them.
[After reviewing the literature], it occurred to me that we should have a nurse going in the homes, interacting with the patient, targeting patterns of health care utilization and self-care management, to see what kind of a difference we could make. So we did a six-month pilot and case-managed 18 patients in the community. In that pilot, we showed a cost avoidance of $80,000.
Also, on the qualitative side, patients were telling us, "Now I know when to call my doctor and when to go to the hospital. I know what my precrisis symptoms are, so I know when to get help to avoid a full-blown crisis admission." Those comments were reflected in the data and in what we’ve seen for the past seven years. Length of stay and emergency department usage have decreased for our client caseload. And, if they are admitted, it’s usually a direct admit, bypassing critical care days and with a shorter length of stay.
So, all the way around, [a community model lets you] decrease utilization while having patients who are more confident that they can manage their CHF or COPD. They know somebody cares about them, they know what to do, and they’re empowered to make good decisions in regard to their health. And we’re benefiting from that in a cost-saving sense.
Our challenge has always been that we’re less than 5% managed care, with about 40% Medicare. People often ask us why we’re trying to reduce admissions. They say, "Don’t you make your money through patient admissions and hospital days?" And the answer is yes, but when you look at our large Medicare population, for which we receive a capitated reimbursement, it makes sense to keep them out, or — if they have to come in — to keep them within a reasonable length of stay.
Q: What sort of orientation was necessary to train your community-based case managers?
A: We have three full-time community case managers, and their peers serve as their preceptors. We try to get them out of the episodic mindset that most acute care nurses have. Many nurses are taught to operate in a medical model where the physician order pretty much drives the care they provide to patients. In community case management, it’s more of a hands-off nursing. The most invasive thing we might do is a blood pressure reading or a pulse oximeter.
It’s about looking at patterns, interacting with patients and asking them what is their definition of health: "If I could do two things for you to make you a healthier person, what would those things be?" Then we would target those community agencies and referral sources that might facilitate that person’s health and wellness.
Community case management is all about interaction—the inter-relational aspect of care rather than interventional.
Q: Do you plan to further expand your community case management program?
A: We’ve often batted about the idea of integrating community case management with home health. Wouldn’t that make sense, because we refer patients back and forth? In some smaller health systems in places like Iowa and North Dakota, some of my peers actually wear two hats.
I don’t know where expansion’s going to go, but I do believe that the future is the community, that more and more care is going to happen up front before the individual patient has acute care episodes. And our job is to make those smooth transitions from community to acute care and then from acute care back into the community.
For more information, contact Lisa M. Zerull, MSN, RN, program director, case management, Valley Health System, Winchester, VA. Telephone: (540) 665-5344.