Geisinger Health Plan targets four key populations when identifying individuals for case management, according to Diane Littlewood, RN, BSN, CDE, and Joann Sciandra, RN, BSN, CCM, regional managers of case management for health services at Geisinger Health Plan.
Our approach to case management at Geisinger is focused on the identification of the high-risk population. Looking at our targeted populations, we focus on heart failure, 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 5. We proactively use our claims system to identify other populations that would require case management. We look to enroll patients at the highest risk — patients with heart failure, COPD, frequent hospitalizations and ER visits — into case management.
The steps for case identification of the high-risk population — the sicker and the sickest — consist of post-hospital discharge and our predictive modeling tool to risk-rank patients and identify those high-ranking patients for enrollment. Another part of case identification is the primary care physician. After relationships are built, the physician will come back to the case manager and say, "I need you to meet Mr. Jones, who is in a room with heart failure, and enroll him into case management." That’s what we look for — enrolling patients and engaging them as they come through the front door of our sites. It’s a little late post-hospital discharge. There are so many opportunities there, but to be able to engage that patient and possibly decrease the risk for admissions, teaching them and monitoring their heart failure from the get-go is the best route to follow.
Once we have our patients identified, our nurses provide a comprehensive assessment that 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 managing this patient in our ProvenHealth Navigator 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.
Templates built into our documentation are NCQA-driven and address the social, physical and behavioral needs and health history of the patient. We develop a patient-centered plan of care based on their risks and goals. 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.