High-touch resources hold down total costs
EMBEDDED CARE MANAGERS increasingly are becoming members of clinical teams in physician offices. They might conduct comprehensive evaluations or call attention to neglected health issues, such as preventive care screenings or vaccinations, making care more effective and efficient.
In 2007, Aetna piloted a program that placed nurse case managers in 36 primary care practices to help manage patient care. At the time, the concept of embedded nurses - case managers, care managers or health coaches - was revolutionary. Instead of anonymous individuals communicating 'with physicians and their patients by telephone, insurers moved RNs, social 'workers or behavioral health specialists into physician offices to work face-toface with staff and patients.
Aetna's telephone case management program produced a 31% reduction in the number of acute-care days compared to fee-for-service Medicare, while the embedded case management program produced an additional 8% to 12% reduction in acute- care days over the four-year program.
'We decided to come up with new arrangements before Accountable Care Organizations came into being,' says Randall Krakauer, MD, Aetna's Medicare medical director.
While the embedded nurses serve only a small percentage of Aetna's members, Dr. Krakauer says there are plans to aggressively grow the program to reach half of its members through embedded case management programs 'within the new few years.
PRINCIPLES OF ENGAGEMENT
Glen Stream, MD, president-elect of the American Academy of Family Physicians (AAFP), says with the focus of healthcare reform on value-based purchasing and better quality, embedded case management programs have the potential to improve care across the continuum.
'The concept of engagement, responsibility and accountability for patients is part of primary care and is an evolving concept central to the principles of the patient centered medical home transformation,' Dr. Stream says.
AAFP eventually 'wants to see embedded case managers in all primary care offices. Dr. Stream, who practices in Spokane, Wash., says embedded case managers are known as 'wilderness guides' in the Pacific Northwest.
'The health system is the 'wilderness for patients,' he says. 'To help patients navigate the system to their best advantage - maintaining good health and 'wellness - does take care coordination, and it's best done in the setting of the medical practice.'
He says there's an advantage to the care model: better patient care and better physician satisfaction. In the long run, it's also more cost efficient for the payer.
The embedded case management model also transforms the medical practice by moving the physician away from the role as sole care provider, creating a team model in which everyone is practicing to the potential of their license.
'For nurses, reaching out to patients over the phone and doing care coordination is clearly 'within their scope of practice and training, and they can do that where the physician doesn't have time in the day,' Dr. Stream says.
AmeriHealth Mercy's Keystone Mercy Health Plan, a managed Medicaid plan in Pennsylvania, recently was recognized by Medicaid Health Plans of America for its embedded care manager program. Through the use of informatics and care managers, the program resulted in a 17% reduction in hospital admissions and a 37% drop in inpatient lengths of stay.
The Pennsylvania-based program originated three years ago from discussions between Keystone and Mercy Health System on how to work collaboratively to serve a key geographic area with an impoverished and underserved population. Currently the program serves 489 members at the Mercy Ambulatory Care Clinic, located in West Philadelphia.
'It was a way for us to immediately share information between the office and the health plan,' says Karen Michael, vice president of Clinical Services for Keystone Mercy Health Plan. 'We have information a mile 'wide and an inch thick. The physician practice has the opposite view - they have information an inch wide and a mile deep. They know 'what's happened in the office and with connected providers, but they don't know 'what happened to members outside ofthe system.'
The pilot program placed care mangers into resident clinics, servicing about 80% ofthe health plan's population. Michael says a key success factor was introducing the change to a practice where a majority of the patients were impacted by the program.
'The care manager and the information set helped us look at the panel from a population perspective,' she says. 'Instead of just looking at those coming in to see their physician, we looked at the practice to see who should be coming in for a visit.'
A community team knocked on doors to remind patients about the importance of preventive care, and on the spot they could call in to schedule an appointment 'with a physician.
While Michael says care managers are a trend throughout the country, the difficulty of implementing a successful program lies in resource allocation. A typical practice deals with seven to nine major payers. Having a nurse care manager for every payer isn't practical.
'There needs to be change at the funding level so practices are funded to develop and implement resources to help all patients,' Michaels says.
The health system maintained its number of patients served 'when the additional preventive care visits were added in, Michael says.
CRITICAL RESOURCE ALLOCATION
Cherokee Health Systems in Knoxville, Tenn., created a similar case manager care model by embedding behavioral health specialists in primary care offices. Cherokee CEO Dennis Freeman says the model is really a patient- centered medical home 'with a skilled behavioral clinician 'who is part ofthe primary care team. Patients exhibiting behavioral issues that impede treatment are immediately connected with the embedded behavioral health professional for evaluation and service.
'Like a diabetic with bad numbers 'who is not adhering to a care regimen like they should, behavioral issues contribute to poor management of chronic medical conditions,' Dr. Freeman says. A lot of insurers are trying to figure out how to do it. We've institutionalized separate silos of care for so long, there are a lot of barriers. A critical barrier is finding providers 'who know how to do it successfully.'
Dr. Freeman says he sees an openness among primary care doctors to explore a new way of practicing. And medical schools are beginning to show interest in training behaviorists to work side by side 'with clinical practitioners.
Patients with behavioral issues, he adds, are frequent utilizers of emergency rooms. Providing them 'with the right care at the right place at the right time cuts unnecessary visits to the emergency room, as well as unnecessary visits to the primary care office.
Deciding how to finance the embedded nurses and support their work is a huge challenge unless a payment stream is created on the front end or cost sharing on the back end.
[Sidebar]
MHE EXECUTIV EVIEW
* Embedded care managers are cost-efficient for payers in the longrun.
* It isn't practical to have a separate embedded nurse for every payer.
* Funding is the biggest issue.
[Author Affiliation]
Kimberly Bonvissuto is a Cleveland-based freelance writer.
