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A medical office case management program that began in July at Sutter Health Central in Sacramento, CA, is drawing praise from initially reluctant physicians and offering veteran case managers a new and particularly enriching care-giving opportunity.
"I really find great value in this position," says Bernadette Damper, RN, BSN, A-CCC, a medical office case manager for Sutter Physicians Alliance who has been a nurse for 26 years and a case manager for the past nine. "This is the most useful I have ever felt."
One of the physicians with whom she works recently told Damper that he and his colleagues at first couldn’t understand why a case manager was needed in their office. Now, Damper adds, the physician says, "We’d love you to be here five days a week all year."
Damper’s assessment of the program is that it has provided "the missing link" for other Sutter initiatives, such as the chronic care program and the case management expertise provided in the hospital and in skilled nursing facilities. (See Hospital Case Management, April 2001.)
"It has really enhanced communication with the rest of the continuum of care team," Damper says. "If the case manager in the hospital is having difficulty persuading a patient who needs more care than can be given at home, [the case manager] can call me, who might know the family better, and we can collaborate. If a patient is not doing well at home, and [the caregiver] sees that something needs to be addressed but can’t count on the patient to communicate that, [the caregiver] can call me."
"I can be there during the physician visit."
When there is a change in the patient’s medication regimen, Damper notes, she can inform the caregiver, as well as alert Sutter’s chronic care team, which can meet with the patient at home to provide additional information.
The medical office case management program began as a way to add value to physicians’ participation in the Sutter Physicians Alliance, says Jan Van der Mei, RN, continuum case management director for Sutter Health Central. In view of the resistance that some physicians have to being in a managed care organization, she notes, "we felt it was important to be aligned with the physicians to support them."
Before starting the program, Van der Mei says, Sutter Health sent physicians a survey to gauge their opinions on such issues as whether it was easy to place a patient directly into a skilled nursing facility or to manage the care of patients who make frequent visits to the emergency department (ED).
The results of the survey indicated that physicians believed there was room for improvement in several areas. For example, 85% disagreed with the statement that management of patients who frequent the ED is easy, and 77% disagreed with this statement: "I do not have to spend a great deal of time with certain complicated patients who primarily have social issues." (See survey results, below.)
At the program’s six-month point, Van der Mei adds, another survey will be done to see if the case management initiative has made a measurable difference.
The following strategic objectives were established for the program:
• Increase patient satisfaction.
Sutter Health already has distributed some patient satisfaction surveys, and the responses have been positive, she says. The survey process, however, is a "work in progress," Van der Mei notes. "Sometimes the case manager talks to the patient, sometimes to the caregiver, so finding the right person to survey has been a challenge."
It also is difficult at times for the patient to connect one of the various professionals she or he dealt with to the case manager referred to in the survey, Van der Mei adds. "They may have one or two contacts with the case manager. We’re trying to improve the process of helping patients know who the survey is about."
• Decrease primary care physician (PCP) visits per 1,000 patients by actively assisting with complicated cases.
The idea, Van der Mei notes, is that patient issues more social than medical in nature could be handled by the case manager, eliminating the need for some physician visits.
• Enable closed practices to open to new members.
"We’ve had a huge problem with closed practices," she says. "I’m not sure if we can impact that, but one of the hopes is that by helping manage complicated cases, [the case management program] will decrease the caseload to the point that some closed practices could be reopened."
• Avoid inappropriate admissions.
When a caregiver comes into the office and says, "I can’t deal with Mom anymore," there may be a tendency for the physician to admit the patient to a hospital because he or she doesn’t know what else to do. A case manager can help in such situations by, for example, arranging a nursing home placement, Van der Mei adds.
• Decrease the volume of ED visits.
"Some patients use the ED as a physician’s office," she says. "Case managers can work with the physicians to develop a contract or a care plan for the patient, which the case manager can help implement or support."
Sutter Health issues a report that identifies patients who are noncompliant, meaning they repeatedly disregard physician instructions regarding medications or other issues, Van der Mei explains. That might mean, for example, habitually going to the ED to get more migraine medication at the last minute, rather than getting the drug through the physician’s office, she says.
Although such action is rarely taken, patients who abuse the system can be disenrolled from the physician practice and from the managed care group, Van der Mei adds.
The patients that physicians initially thought to refer to their new case managers were those with mental health issues, she points out, and the fit was a good one.
"Most of the managed care contracts have mental health carved out,’ and it is difficult to find who your HMO mental health providers are," Van der Mei says. "The patients were not able to get care, when you’re severely depressed, you don’t feel like making 10 calls [to find the appropriate provider]." The office case managers, she adds, were able to help navigate the HMO carve-outs and get the proper care for those patients.
Although physicians initially were skeptical about the case management program, Damper says, they now recognize that it can make a positive difference in their patients’ outcomes. Her own interactions with patients and caregivers have ranged from helping decipher the changes in copays for Medicare HMOs to taking a proactive approach to nursing home placement, she explains.
Some medications that formerly were covered by Medicare are no longer covered, Damper points out, and some are covered but with different copays than before. She has helped find solutions for patients who were noncompliant because of financial concerns regarding their medications, she notes.
"With some patients, we need to find out if we can substitute a medication," Damper says. In other cases, she says, "we get in touch with the drug company representative and see if there is a [financial assistance] program they can go on." Many drug companies will supply free medication to a patient if it’s been determined the person needs a specific drug and can’t afford to buy it, Damper adds.
In other cases, she says, a complicated drug regimen needs to be simplified or explained. That could involve a referral to Sutter’s education program for diabetics, for example.
The goal with nursing home placements, Damper notes, is to encourage physicians to refer patients to her when the patient appears to get weaker with each visit, or when the caregiver looks haggard and is not coping as well as before.
"I like to get involved as early as possible so the family and the patient have more choices," she says. The patient may be eligible for long-term MediCal coverage, Damper explains, but because of the waiting period required might have to go in as a private-pay patient if the placement is done at the last minute.
Arranging a placement when the patient can wait at home for a couple of weeks also makes it more likely that a geographically convenient location can be arranged, she says.
Having a case manager involved can prevent a patient who may need only temporary placement in a nursing home from being admitted and "forgotten," Damper points out. "I had a patient with rheumatoid arthritis who couldn’t walk to the bathroom because of the amount of pain she was experiencing. The caregiver couldn’t manage her."
The patient was admitted to a nursing home, she says, but with the purpose of working on pain control and mobility. "With some adjustments we were able to make, she is now on a pain control regimen that works," Damper adds.
"I was able to keep abreast of her condition, so she was able to get in and out and be back home with her family for the holidays," she says.
Medical office case managers can play a key role in addressing end-of-life issues before a patient is in the ED being put on life support, she notes. "If a patient is losing the ability to take oral nourishment, we can address what the person’s wishes are, so when the time comes, things aren’t done that he or she didn’t want done."
Before assuming her position, Damper says, she had been a medical/surgical case manager for Sutter, performing utilization management of both bed days and resources.
She also had discharge planning responsibilities. Asked to compare her previous job with her current one, she notes that while her mission is much the same, the way it is perceived is vastly different.
"One of the purposes of my being [in the medical office] is to ensure that the patient is treated in the most efficient location, at the appropriate place at the most appropriate time, Damper points out. "We still have utilization on our minds."
But unlike hospital case managers and discharge planners, she’s no longer the "firing point" of families who think a patient is being released too soon and physicians who think they’re not getting to make decisions, she says.
"I’m basically doing the same thing," Damper adds, "but because it’s a noncrisis situation, what I’m doing is perceived better."
[For more information on Sutter’s medical office case management program, contact:
• Jan Van der Mei, RN, Continuum Case Management Director for Sutter Health Central, Sacramento, CA. Telephone: (916) 854-6896. E-mail: firstname.lastname@example.org.]