Identifying Target Populations for Case Management

Friday, April 9th, 2010
This post was written by Melanie Matthews

Diane Littlewood, R.N., and Joann Sciandra, R.N., regional managers of case management for health services at Geisinger Health Plan, define targeted populations for case management and initial enrollment steps.

At Geisinger, our approach to case management is focused on the identification of the high-risk population. Looking at our targeted populations, we focus on heart failure, chronic obstructive pulmonary disease (COPD), the frail elderly and any patient with transition of care. The majority of our case referrals come through at hospital discharge and admissions. Anyone who is identified with a hospitalization and a discharge is automatically a high risk with a risk rank of five. We proactively use our claims system to identify other populations that would require case management. Patients that are at the highest risk — patients with heart failure, COPD, frequent hospitalizations and ER visits — are high risk and we look to enroll them into case management.

Once we have our patients identified, our nurses provide a comprehensive assessment, which comes from our assessments and stratifications. This assessment identifies the driving issue behind the case and where we have to start with this patient to make a difference. We develop an action plan based on the issue. Having a case manager on site gives us the ability to interact with the healthcare team who is managing this patient in our ProvenHealth NavigatorSM site. Our case manager has the ability to sit down with the primary care site doctor and show them the action plan. That primary care site doctor then has the ability to make changes in that plan. It’s comprehensive and collaborative. We have found that our plans work better when the primary care site physician is brought into the plan from the beginning.

We have templates that are built into our documentation pieces that are NCQA-driven and that address the social, physical and behavioral needs and health history of the patient. We develop a patient center plan of care based on their risks and the goals that they have. We’re talking about short- and long-term patient goals as well as how we hope that their health status, and the care that we deliver, will move them to quality care and a good quality of life. We manage those acute care exacerbations with targeted action plans. We’re hoping that if someone has heart failure and needs diuresis, that we don’t have to send them to an ER for that. The sites are set up and the nurses and nursing staff have all been trained so that they are able to start IV’s and give some Lasik™ in the clinic setting. Or, if there is possibly dehydration, they can hydrate someone there instead of sending someone for a long wait in an ER. Our nurses are engaged with community resources and strong relationships with area agencies on aging and different communities — again resources that we tap into frequently.

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