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A few years ago, Catherine Beatty, RN, MSN, faced a frustrating problem common to case management — coordinating care for just a few very sick patients was keeping her case managers tied up for days on end.
"These were complex patients with a lot of comorbidities," says Beatty, manager of medical services for BlueCross BlueShield of South Carolina, based in Columbia. "Many of them were terminally ill. They needed more intensive case management than our case managers could give them."
Then, in 1998, BlueCross BlueShield of South Carolina signed up for the Complex Care Management program offered by Franklin Health, an Upper Saddle River, NJ-based company specializing in managing the care of patients who need high-intensity case management. The American Accreditation HealthCare Commission-accredited company provides services for large insurance and employer populations.
The result has been cost savings to the insurer and an increase in efficiency for its in-house case managers. Members whose care is managed by Franklin Health’s care managers have a high degree of patient satisfaction and have reported a tremendous increase in quality of life for themselves and their families.
"This program really makes a difference to the patients and their families. The savings are a bonus," Beatty says.
In fact, it’s not unusual for Beatty to get a letter from a patient or family thanking BlueCross BlueShield for providing the service. "If you help a patient make decisions and coordinate care among providers, the patients truly appreciate it," she adds.
Franklin Health focuses on the complex patients, the less than 1% of the population that accounts for a significant proportion of health care costs, according to Jeanne Clement, RN, MPH, senior vice president of operations for Franklin Health.
About 60% of the BlueCross BlueShield of South Carolina patients in the program have cancer, and most are terminally ill, according to Michelle Hendershot, account director for Franklin Health.
Other patients in the program include those with complex comorbidities such as complications from diabetes, people who are recovering from catastrophic injuries and need an intensive rehabilitation regime, and premature infants.
Franklin hires and trains local nurses for its complex care programs. The nurses are required to sit for the Certified Case Manager examination as soon as they are eligible. Their caseloads vary from 20 to 25 patients at a time, depending on the complexity of the case.
The Franklin care managers set goals that focus on issues that frequently need to be addressed in complex patients: patient knowledge and choice, case management treatment plan, family and living environment, terminal care planning, pain and symptom management, physician and provider support, and benefit plan management.
The Franklin nurse case managers make at least one on-site visit with patients (more if required) and talk to the patients and families by telephone at least once a week. They work at home, on a flexible schedule, and are available if a crisis arises.
"They are the eyes and ears of the health plan. They can see the family dynamics, the financial situation, and get a total picture that they might not get over the telephone," Clement says.
The care managers develop a plan of care and work with the patient’s physicians, the family, and community resources to see that the patient receives the care and support he or she needs.
"The key part is that we really coordinate and facilitate among different providers of care. Clear communication is the key. Patients may not know what to ask. They don’t know how to link all the providers who are involved in their care," Clement says.
Patients in the middle of a medical crisis have so many decisions to make that many haven’t been able to stop and consider all their options, Clement says. The Franklin care managers sit down with the patients, explain their conditions, answer questions, and help patients understand their disease and their treatment plan. They review the options and help the patients and families set realistic goals.
For instance, in the case of terminally ill patients, the care managers will educate the patient and the family about advance directives.
They work closely with the physicians making sure patients absorb what their physician is saying. "Often, the physician gives the patient information and the patient simply does not understand it. We review it with them in a less stressful environment, explaining what might happen with each option," Hendershot says.
The case managers are available by telephone and often get calls from the patients about symptoms and problems.
"Our care managers form a close relationship with the patients, which allows them to be more proactive and anticipate problems. They have the opportunity to get to know patients and devote a lot of time to them to help make sure they don’t get into a crisis situation," Clement says.
For example, if a patient faces the possibility of dehydration from chemotherapy, the care manager will develop a plan of care to treat the symptoms before hospitalization is required. This may include making sure the patient has adequate medicine to treat nausea and vomiting or arranging for a home care agency to provide intravenous hydration.
"The care managers facilitate direct care in a less costly setting because the patient will call them more quickly than they’ll call the physician," Beatty says.
Franklin uses a team approach to managing the patients. The care management company has practicing physicians on staff who are part of the team. The care plan for each patient is reviewed regularly by a team of nurses and physicians.
The Franklin Health physicians make it clear to the treating physicians that their role is to assist patients in getting the care they need, and not to challenge their treatment.
"We’ve had a number of provider referrals for this program. The patients that Franklin Health manages are very resource-intensive in the physician’s office, and the doctors are glad to have another resource to lean on," she adds.
When BlueCross BlueShield of South Carolina first began its collaboration with Franklin Health, 250,000 covered lives from its HMO and fully insured population were eligible for the program. Because of the success and the high degree of patient satisfaction, the program has grown to more than 700,000 lives with the addition of self-funded programs that purchase the program as an option.
Franklin Health gives BlueCross BlueShield of South Carolina an annual analysis of effectiveness, including cost savings, patient satisfaction, and quality of life. "They have contract requirements for patient satisfaction outcomes, and if they don’t meet them, there are penalties. They have always exceeded the requirements," Beatty says.
(For more information on Franklin Health, see the firm’s web site at www.franklinhealth.com.)