Archive for June, 2012

Meet Case Management Manager Helen Schreiber: Dispelling the Notion of “Nurse Police”

June 29th, 2012 by Cheryl Miller

Helen Schreiber RN, BS, CCM, Executive Vice President of S&H Medical Management Services, Inc.

HIN: Tell us a little about yourself and your credentials.

Helen Schreiber: I attended nursing school after getting married and having two kids. I took all of my science classes at the junior college level while I was working part-time at a deli. I knew I was going to attend a diploma program because I couldn’t afford to go to a four-year university. Unfortunately, at that time, hospital programs would only accept you if you were single. I had faith and sure enough, after being told in 1979 and 1980 that I could not be married and attend, in 1981 I was told that I could attend if I lived in the dorm, and then Ravenswood Hospital School of Nursing finally accepted me in 1982 and allowed me to commute. There were 88 students in my class and more than half of them were married with kids. I graduated from there in 1985. I then received my bachelor of science in health arts (BSHA) from St. Francis in 1991. I am currently a certified case manager (CCM). Prior to that I was a Mobile Intensive Care Nurse (MICN), a Certified Emergency Nurse (CEN) and a Trauma Nurse Specialist (TNS).

What was your first job out of college and how did you get into case management?

I worked nights on an ortho unit (22 patients on my team) and then moved on to my dream job in the ER. I loved working nights there. When my kids got older I knew I needed to work days and I found an ad for a case manager.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I was truly in my element in the ER. I loved the fact that you could never predict how your shift would end. I love the chaos...and case management fills the same needs for me. Plan but be prepared for any eventuality.

In brief, describe your organization.

S&H Medical Management Services, Inc. is an independent, regional, women’s owned medical and vocational case management firm. We are completely virtual! I am most proud of the fact that we have 12 S&H babies. By that I mean, kids that were not in child care because of our at home positions with flex hours.

What are two or three important concepts or rules that you follow in case management?

  • First and foremost, be honest.
  • The second most important thing is realizing that the availability of healthcare is a gift. It is there for the patient to accept. You can wrap it up and make it as attractive as you can but you cannot make a person open the gift. That is very difficult for some people to accept.

    What is the single most successful thing that your organization is doing now?

    We have the best vocational department in Illinois. At a time when jobs are being lost, our vocational staff continues to produce a product that rocks. We have doubled the size of our vocational department during the past two years and it is due to great outcomes and special people.

    Do you see a trend or path that you have to lock onto for 2012?

    The economy continues to impact this industry. I believe creative marketing is key at this time.

    What is the most satisfying thing about being a case manager?

    I truly feel humbled to have people allow us into their lives and share the details with us at such a stressful time. That is the best thing about being a nurse.

    What is the greatest challenge of case management, and how are you working to overcome this challenge?

    Involving the injured worker into the process and making certain that the case manager is honest with him is what is most beneficial to the process. Many times the case manager is perceived as the ‘nurse police’. Those words were spoken to me by an injured worker…..

    What is the single most effective workflow, process, tool or form case managers are using today?

    At S&H I believe our proprietary software for case management documentation has made our staff more effective. S&H has also adapted the CMSA adherence tools and we utilize these tools to assist with adherence assessments.

    Where did you grow up?

    I was born in Austria. My family immigrated to the United States when I was 18 months old. I grew up in Chicago and became a U.S. citizen in the early 60’s. I attended Good Counsel high achool.

    What college did you attend? Is there a moment from that time that stands out?

    I am a child of the 70’s when not everyone went to college - at least not right away. I will never forget how overwhelmed I was when I first went to register at Wright Junior College in Chicago for my very first college course. The hardest thing to do is to go back to school. I remember telling my boss that I would be 33 by the time I finished school. He said you will be 33 in five years anyway.

    Are you married? Do you have children?

    I have been married to Roland Schreiber for 35 years. It is a second marriage for both of us. We have two kids: Erik is 38 and a cop in Chicago. Monika is a teacher, married to Pat and they are the parents of my two terrific grandchildren, Elizabeth and Olivia, who all live in Texas. We spend winters there in order to spend more time with the girls. While my daughter is certified as a teacher she now works for S&H and has since college. This has allowed her to work from home.

    What is your favorite hobby and how did it develop in your life?

    Sewing when I have the time. My current project is new drapes. And I am absolutely crazy about dogs. We currently have three, Gretchen the golden retriever, Schatzi, the rescue (a German Shepherd mix) and Tinker, another rescue (a Shitzu).

    Is there a book you recently read or movie you saw that you would recommend?

    The Total Money Makeover by Dave Ramsey is a great book. It helps people learn to live debt-free and have more control of their lives.

    Click here to learn how you can be featured in one of our Case Manager Profiles.

  • Aftermath of SCOTUS Healthcare Reform Ruling: The Country Reacts

    June 29th, 2012 by Patricia Donovan

    From retailers to religious groups to every sector of the healthcare industry, reactions were immediate, passionate and divided to yesterday's Supreme Court validation of the Affordable Care Act — a.k.a. Obamacare.

    The highest court in the country upheld the constitutionality of the individual mandate built into the healthcare reform bill, but rejected the law's right to penalize states that choose not to participate in new Medicaid programs by taking away their existing Medicaid funding.

    Many states and healthcare organizations were waiting for the ruling before deciding whether to implement the many programs spelled out in the Affordable Care Act.

    Here are excerpts from official statements published around the Web yesterday:

    American Medical Association

    "...We are pleased that this decision means millions of Americans can look forward to the coverage they need to get healthy and stay healthy....This decision protects important improvements, such as ending coverage denials due to pre-existing conditions and lifetime caps on insurance, and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents' health insurance policies. The expanded health care coverage upheld by the Supreme Court will allow patients to see their doctors earlier rather than waiting for treatment until they are sicker and care is more expensive. The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans..." (Jeremy A. Lazarus, MD, president)

    Restore America's Voice Foundation

    "The Court threaded a Constitutional needle in redefining the individual mandate as a federal tax. It's disappointing but not the final recourse for the American people. Now it is time for the legislature to do its job representing the will of the American people for full and final repeal of this ill-considered legislation...It must be repealed in its entirety or Senate Democrats will have to go home and explain their flawed definition of faithful representation. If they won't represent the will of the people, then how have they earned the right to serve?" (Ken Hoagland, chairman)

    Kaiser Permanente

    "Today’s Supreme Court decision on the federal healthcare reform law resolves much of the legal uncertainty over implementation of the law’s provisions. While acknowledging that political uncertainty still remains, in the interest of our members we plan to continue our extensive reform implementation efforts, which began two years ago when the law first became effective. We want our members to know that they need not be concerned about any disruption of their coverage resulting from the Supreme Court’s decision today..." (Unattributed, published as "Our Point of View")

    America’s Health Insurance Plans’ (AHIP)

    “...Health plans will continue to work with policymakers on both sides of the aisle to make coverage more affordable, give families and employers peace of mind, and promote choice and competition. Health plans also will continue to lead efforts to reform the payment and delivery system to promote prevention and wellness, help patients and physicians manage chronic disease, and reward quality care.” (Karen Ignagni, AHIP president and CEO)

    Primary Care Development Corporation (PCDC)

    "We are enormously pleased that the Supreme Court recognized the importance of the Affordable Care Act to millions of Americans and upheld the law, though it is disappointing that the ruling also weakened a provision supporting Medicaid expansion. (Ronda Kotelchuck, CEO)

    National Association of Public Hospitals and Health Systems (NAPH)

    "We are pleased by the Court's decision today to uphold the Affordable Care Act's (ACA's) individual mandate, which will broadly expand health care coverage. We also are pleased that the decision retains other positive elements of the ACA, including initiatives to promote innovation, preventive care, and community-based collaborations. But our initial assessment of the decision leaves us concerned by its potential to limit Medicaid expansion, which could strand millions of our most disadvantaged people without access to basic health care coverage." (Bruce Siegel, MD, MPH, NAPH president and chief executive officer)

    National Retail Federation:

    “As the voice of retailers of all types and sizes, we’re disappointed by today’s ruling. The Court missed an opportunity to redress the many shortcomings of the law. As it stands, the law wrongly focuses more on penalizing employers and the private sector than reducing health costs. For these reasons, NRF has been a consistent skeptic of the Affordable Care Act....Although the Court upheld the law’s constitutionality, many problems remain: it penalizes employers too much; it doesn’t do enough to reduce the cost of healthcare; and it is unreasonably complicated and difficult to implement and administer...This law will have a dramatic, negative impact on every employer and employee in the United States and further constrain job creation and economic growth." NRF President and CEO Matthew Shay

    National Lutheran Church — Missouri Synod

    “In light of today’s ruling by the U.S. Supreme Court on the constitutionality of the Patient Protection and Affordable Care Act (PPACA), we remain opposed to the controversial birth control mandate, which is one of the requirements included in the law. The Court’s decision today guarantees that we will continue to bring awareness to the threat to religious liberty represented by the birth control mandate, which requires virtually all health plans, including those of religious organizations, to cover birth control drugs and products that could cause the death of the unborn. We are opposed to the birth control mandate because it runs counter to the biblical truth of the sanctity of human life and creates a conflict of conscience for religious employers and insurers, who face steep penalties for non-compliance based upon their religious convictions. (Rev. Dr. Matthew C. Harrison, president)

    American Hospital Association (AHA)

    "Today's historic decision lifts a heavy burden from millions of Americans who need access to health coverage. The promise of coverage can now become a reality. The decision means that hospitals now have much-needed clarity to continue on their path toward transformation." (AHA President and CEO Rich Umbdenstock)

    Blue Cross Blue Shield Association (BCSA)

    “BCBSA has long been committed to ensuring everyone has high quality, affordable healthcare coverage. We will continue to implement the law while working with policymakers to fix provisions that will increase costs, such as the health insurance tax that will add hundreds of dollars to families’ premiums each year. On behalf of our 100 million members, Blue companies will continue to lead efforts in their local communities — partnering with doctors, nurses, hospitals and others — to rein in costs, improve quality, help people stay well and better manage their care when they need it.” (President and CEO Scott P. Serota)

    Diets, Doctors and Obesity: Heavier Weight for Primary Care

    June 27th, 2012 by Patricia Donovan

    It's only Wednesday, but it's already been a weighty week for obesity.

    On Tuesday, the U.S. Preventive Services Task Force recommended that primary care doctors screen adult patients for obesity. The task force further suggested that healthcare professionals offer or refer obese persons to a comprehensive weight loss and behavior management program with 12 to 26 sessions in the first year.

    But what type of weight loss program is optimal, and what's the most effective diet to follow? Separate studies appearing in the current issue of the Journal of the American Medical Association (JAMA) offer some guidance for physicians in these areas.

    Researchers in the first study, in search of effective but resource-efficient weight loss treatments, compared a standard behavioral weight loss intervention (SBWI) with a stepped-care weight loss intervention (STEP). The JAMA article notes that stepped-treatment approaches customize interventions based on milestone completion and can be more effective while costing less to administer than conventional treatment approaches.

    All participants were placed on a low-calorie diet, prescribed increases in physical activity, and attended group counseling sessions ranging from weekly to monthly during an 18-month period. The SBWI group was assigned to a fixed program. Counseling frequency, type, and weight loss strategies could be modified every three months for the STEP group in response to observed weight loss as it related to weight loss goals.

    In addition to determining the mean change in weight over 18 months, the study also measured additional outcomes including resting heart rate and blood pressure, waist circumference, body composition, fitness, physical activity, dietary intake and cost of the program.

    Researchers concluded that among overweight and obese adults, the use of SBWI resulted in a greater mean weight loss than STEP over 18 months, but that compared with SBWI, STEP resulted in clinically meaningful weight loss that cost less to implement.

    But let's back up a minute to that low-calorie diet both groups followed. The second published study found that not all calories — and low-calorie diets — are created equally. Researchers at the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital studied the effects of three diets, each of which contained the same number of calories:

    • Low-fat, which is typically recommended by the U.S. government and American Heart Association, aims to reduce overall fat intake.
    • Low-carbohydrate, modeled after the Atkins diet, reduces almost all carbohydrate intake.
    • Low-glycemic, which aims to keep blood sugar levels steady by choosing natural foods and high-quality protein, carbohydrates and fats.

    Even though all three diets consisted of the same amount of calories, researchers determined that the low-glycemic diet came out on top: aside from helping to stabilize metabolism even after weight loss, existing research suggests that low-glycemic diets help people feel fuller longer and experience improved sense of well-being, as well as improved mental and physical performance.

    You can learn more about this research in Thriving, the Boston Children's Hospital pediatric health blog.

    For Americans identified as overweight or obese and for the healthcare providers assigned to treat them, there are no easy solutions. I leave you with these thoughts from George A. Bray, MD, excerpted from his editorial on these obesity studies that appears in the same JAMA issue:

    Obesity is one of the most important and most frustrating health problems that physicians treat, and the studies in this issue of JAMA provide valuable information for clinicians who treat obese patients. It may be possible to have a more individualized approach to weight loss, rather than a one-size-fits-all approach. The most efficient treatment approach incorporates periodic reassessments and adjustment of the weight loss regimen based on a patient's success at any given time. Although the exact relationship between dietary composition and weight maintenance remains unclear, calorie restriction is more important than diet composition in administering weight loss regimens.

    Healthcare 80/20 Law Saves Consumers Over $1 Billion

    June 25th, 2012 by Cheryl Miller

    Consumers should check their mailboxes this August


    Insurance policy holders just might have some extra spending money this summer.

    According to the HHS, insurance companies that don’t meet the 80/20 healthcare rule of spending, which requires them to spend at least 80 percent of consumers’ premium dollars on medical care and quality improvement, and the remainder on administrative costs, must provide their policyholders a rebate for as much as $151 no later than Aug. 1, 2012. Consumers can expect a notice from their insurance company informing them of the 80/20 rule, whether their company met the standard, and, if not, how much of the difference between what the insurer did or did not spend on medical care and quality improvement will be returned to them.

    Eligible healthcare organizations have already been reimbursed by the government for adopting EHRs for meaningful use. In fact, the CMS met its goal of getting 100,000 organizations on board with its EHR incentive program three months earlier than planned: more than 110,000 eligible healthcare professionals and over 2,400 eligible hospitals have received over $5.7 billion in payments as of the end of May. The end of 2012 was the original target goal. Officials hope the increasing use of EHRs will provide better patient care, cut down on paperwork, and eliminate duplicate screenings and tests.

    Pharmacists could help manage the country’s healthcare costs if the results of a new study from Walgreens prove fruitful. Walgreens pharmacists trained over 4,500 patients starting self-injectable diabetes medication for the first time on appropriate injection technique, side effect management and the importance of adherence to therapy. Pharmacists also provided a follow-up assessment at the patients’ next refill meeting. Initial results showed that patients who received two counseling sessions with a pharmacist were 24 percent more adherent after 90 days and had an additional eight days of therapy compared to a usual care control group.

    Employers, too, are looking for ways to keep their costs down, with employee healthcare plans a prime target. A study from J.D. Power and Associates reveals that almost 50 percent of employers might pursue alternate methods of employee healthcare coverage, including defined contributions, vouchers and exchange purchasing. A smaller percentage of fully insured and self-funded employers said they might discontinue sponsoring employee coverage completely. Details in this issue.

    And lastly, we have a new survey on asthma management. Asthma drives a lot of healthcare utilization — half a million hospitalizations and nearly 2 million emergency department visits in 2009 alone. We invite you to share how your organization is managing asthma in the populations you serve by July 27, 2012. In return, we'll e-mail you an executive summary of trends in asthma management.

    All this and more in this week's Healthcare Business Weekly Update.

    8 Priorities of Healthcare Case Managers: Patient Advocacy Tops List

    June 25th, 2012 by Jackie Lyons

    Patients should be the number one priority, and patient advocacy the most important concept for case management, say a group of healthcare case managers recently interviewed by the Healthcare Intelligence Network.  Other priorities voiced by these case managers include the following:

    • Stewardship
    • Discharge planning
    • Honesty
    • Family-centered approach
    • Communication
    • Ethical treatment of all touched by the case management process
    • Encouragement of self-care
    • HIN asked healthcare case managers to share two or three important rules they follow.  Here is what they had to say:

      Hillary Calderon, RN, Senior Manager of Corporate Case Management for HCA: Keep focused on your goals, which should be patient and family first. Implement the right plan for the patient and the family. Remember what is in scope for you to do. Do what you can, and concentrate on that. Don’t get caught up in “extra” duties as assigned, unless it pertains to your goal.

      Linda Conroy, RN, BSN, Clinical Integration Case Manager for Hartford Physician Hospital Organization (HPHO): Always try to understand what the patient is feeling. Allow the patient and family to guide you in what they want and how they want to reach their goals. Do no harm.

      Stacey B. Hodgman, MS, RN-BC, CCDS, CPUM, District Director of Case Management for Kindred Healthcare, Board of Directors for the Case Management Society of New England: First and foremost is patient advocacy. I tell new case managers that if they have a need to be popular, case management may not be the career choice for them. Case managers have an obligation to the patient first, then to the organization. Oftentimes, this can cause conflict between administration and case management.

      Secondly, ensure stewardship for both the patient and for the organization you work for. Ensure that the patient receives the right care, in the right setting, at the right time. Continuing inpatient care in the hospital longer than a patient needs to be there not only places them at risk for hospital-acquired conditions, but also continues to utilize their hospital benefit, and in the Medicare population, this is limited. Hospitals are often paid as a prospective payment system - they receive one amount regardless of length of stay or resource consumption. The case manager helps ensure appropriate utilization of resources and timely discharge planning.

      Lastly, discharge planning is probably the case manager’s most important responsibility. Ensuring resources are in place, that patient/caregiver teaching has been completed, and that they are able to verbalize an understanding of the discharge plan are critical steps in facilitating a safe and appropriate discharge plan. The role of the case manager is to facilitate this through the entire interdisciplinary team. They need to ensure that the pharmacy has reconciled medications, diabetic teaching has been completed by the nurse, equipment needs and use have been reviewed by physical or occupational therapy, care for a percutaneous endoscopic gastrostomy (PEG) tube or wound has thoroughly been reviewed with the patient/caregivers. The case manager also needs to ensure that there is a solid understanding of who the post-discharge caregivers are, what appointments need to be made or kept and a phone number to call if there are any issues that arise post discharge from the hospital. Not only is thorough discharge planning critical to patient safety, but also to preventing rehospitalizations.

      Barbara King, BSN, RN, Co-Founder and President of NurseValue, Inc.: The number one rule in both business and nursing is to always be honest. Next, the nursing process is useful when providing any service: assessment, diagnosis, planning, implementation and evaluation. Lastly, continue to learn throughout your career. You never know when a tiny bit of information will help to solve a pressing issue.

      Barbara (Bobbi) Kolonay, RN, BSN, MS, CCM, Owner of Options for Elder Care, Medical Care Management Services for Seniors: We use a family-centered approach to case management. We work with a very large multidisciplinary team including physicians, holistic practitioners, home care agencies, hospice agencies, attorneys and financial planners. Our motto is to provide the most care and cost-effective service. Statistically, we save the client more money than they spend on our service. We make sure that each and every one of our clients lives and dies with dignity.

      Sonia Morrison, RN, CM, BSN, RN case manager at Salinas Valley Memorial Healthcare System (SVMHCS), Nurse Assessment Consultant and Educator for veterans at Visiting Angels of Santa Cruz: The keys to successful utilization review and discharge planning and collaboration are communication, including written documentation and collaboration with the full team, including the patient, family, doctor, nursing staff and other providers. It is important to assess and educate patients within the first 24- to 48-hours of admission. Balanced self-care allows me to serve my team the best.

      Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CEAS II, Founder and President of VP Medical Consulting, LLC.: Patient advocacy is always first! Advocacy is the basis of not only case management, but nursing in general. A huge part of patient advocacy involves education. A patient cannot realistically expect to know what he or she wants to do unless they fully understand their options. Once the information is understood, the patient is allowed to make a decision on the direction of their medical care. However, that does not mean the contracted carrier  is responsible for the payment of those services. This is the most difficult thing for our nurses to understand. They are required by their nursing license to advocate for the patient, but at the same time they are responsible for understanding that just because a service is needed does not mean that our client is responsible for providing it. This is why I prefer to hire nurses with excellent critical thinking skills who are comfortable ‘outside the box.’

      Another rule in our company is that we are always working to establish rapport with our patients. Since we work in a highly litigated area (workers’ compensation), establishing rapport is essential in the reduction of litigation expenses. Many times cases are brought into the courtroom because the patient does not understand the process or feels forgotten. Allowing him or her to have a sounding board helps, as does having a case manager to help them understand complex processes or issues. We educate our patients on medically related issues as well as their rights and responsibilities under the state workers’ compensation system. This is just another way that our legal background and training helps to minimize expenses of the cases for which we manage.

      Linda Van Dillen, RN, BA, CCM, Executive VP/Partner of S&H Medical Management Services, Inc.: First, I believe in the ethical treatment of all parties involved in the case management process. Secondly, I work towards an adherence model vs. a compliance model of case management. I strive to ensure all parties have the information they need to make an informed decision.

      Miriam Weiss, MSN, RN, CCM, Care Manager at Amerigroup Corporation, Care Manager Consultant, Per Diem, at CareManagers Inc.: It is important to encourage self-determination, and provide tools to enhance self-care abilities that promote and improve healthier behaviors.

      For more success strategies, and metrics and measures on current and planned case management initiatives, check out 2012 Healthcare Benchmarks: Case Management, a new 60-page resource from HIN presented in more than 70 easy-to-follow graphs and tables.

    Case Managers Positively Impact Patient Experience and Satisfaction

    June 22nd, 2012 by Cheryl Miller

    Case managers continue to positively impact healthcare delivery. According to 19 percent of respondents to our recent survey on improving patient experience and satisfaction who said that case managers were primarily responsible for this area of care, 90 percent said that their case managers had significantly increased patient satisfaction. The survey also found that communication between patients and members was considered the weakest link.

    In tandem with overall population health and cost of care, patient satisfaction with the healthcare experience is influencing quality ratings and value-based reimbursement levels.

    Nearly 19 percent of respondents to the 2011 survey on Improving Patient Experience & Satisfaction said case managers have primary responsibility for efforts to improve patient/member satisfaction. The survey captured the efforts of organizations working to improve patients’ and members’ experience and satisfaction with their care. Responses provided by 146 healthcare organizations indicate that quality of care is the most important aspect of the care delivery experience. In addition, almost all responding organizations cover the topic of quality of care in their patient satisfaction surveys. However, almost 85 percent of respondents are not satisfied with their organization’s patient satisfaction scores on the CMS Hospital Compare site.

    Additionally, the survey identified communication as the aspect of the patient/member experience most in need of improvement.

    Case management has a substantial impact on patient satisfaction. Most respondents — 90 percent — to the 2011 survey on Healthcare Case Management said case management efforts had increased patient satisfaction.

    Aetna’s Compassionate Care Program Incorporates Holistic, Member-Centric Case Management

    June 22nd, 2012 by Cheryl Miller

    When a loved one is dying, continued support and compassionate care from clinicians and case managers can be a “lifeline,” at least to one member whose spouse went through Aetna’s Compassionate Care program.

    And that’s one of the main goals of the program, according to Dr. Joseph Agostini, senior medical director for Aetna Medicare, who spoke to the Healthcare Intelligence Network during its Advanced Illness Care Coordination: A Case Study on Aetna's Compassionate Care Program, a 45-minute webinar on June 13, 2012: to provide additional support to members with advanced illness and their families/caregivers, and help them access optimal care, so they can get more of the kind of care they want, and spend less time in the ICU and hospital.

    A person has advanced illness if

    "...he/she has one or more conditions that progress enough that general health and functioning decline, and treatments begin to lose their impact."

    Aetna's Compassionate Care Program is a nurse case management initiative that specifically targets patients with advanced illness, and it has had a major effect on healthcare utilization and quality outcomes, he said.

    The need for such a program is crucial, Dr. Agostini said, given the increasing number of elderly people with advanced illness. Studies show that:

  • The rate and rise of older Americans is growing, and 10,000 baby boomers are aging into Medicare a day; and
  • The rate of Americans 85 years and older is growing; and
  • An estimated 30 percent of Medicare costs are incurred in the last year of life; and in the last month, 80 percent of costs are for hospitalizations; and
  • While most deaths occur in the hospital or nursing home, most Americans prefer to die at home.
  • While not a goal, Dr. Agostini stresses, the Aetna Compassionate Care program has increased hospice selection rate.

    The program relies on nurse case managers to identify members for the program, and then to act as a support system for them and the community supporting them.

    There is no specific training, instead, Aetna employs a “holistic, member-centric case management plan,” and RN case managers “should have the ability to support patients through all phases of life,” says Dr. Agostini. “Addressing patients holistically is crucial, because comorbidity is common, “ he explains. According to a JAMA study, people at the end of life value different things, including freedom from pain, and having family present, and Aetna's goal is to honor the differences.

    Case managers can help members to understand their options, address pain and other symptoms, help plan advanced care support, and provide education and awareness of resources and online tools. Training is key, Dr. Agostini says, and includes motivational interviewing, technical training, and "lunch and learns."

    Aetna’s involvement in compassionate care was prompted by significant gaps in care for the elderly, especially end of life care. Part of the problem is a serious shortage of specialists: data shows there is one oncologist per 141 new cancer patients versus one palliative medical doctor for every 1,200 patients with serious or life-threatening illnesses.

    And there are definite benefits to introducing palliative care options sooner. According to a study from the Dartmouth Atlas of Health Care, patients pursued less medically aggressive care but lived more than two months longer, had fewer depressive symptoms and improved mood and quality of life. The explanation could be that “earlier referral to hospice could lead to better symptom management.”

    As with any program, there are certain endemic challenges, including inadequate pain treatment, late referrals, difficulties determining prognosis, and lack of emotional support.

    But overall the program has resulted in significant results, including:

  • 82 percent reduction in acute inpatient days; and
  • 77 percent reduction in ER visits; and
  • 86 percent reduction in ICU days; and
  • Improved quality of life for Aetna members and their families.
  • This last result was perhaps most important for the member who reported on her husband’s passing in hospice while in Aetna’s program. Two days before their 49th anniversary he gave her a piece of jewelry that his daughter had helped him to purchase; it was something he’d done every year since they were married. Two days later he lost consciousness, but she expressed gratitude to the team for having been given this final memory.

    Joint Contracting Key Component of Clinical Integration Program

    June 20th, 2012 by Cheryl Miller

    Joint contracting is the 'glue' that keeps the Advocate Physician Partners (APP) clinical integration program together, explains Mark Shields, MD, MBA, APP senior medical director and vice president of medical management for Advocate Health Care.

    To put together our clinical integration (CI) program, we have negotiated with all of the carriers in our marketplace. There are 10 clinically integrated contracts with our 10 lead carriers. The funding of the CI programs is based on a percentage of allowable physician billings. That is how we create the cash flow for our pay for performance (PFP) program and key infrastructure. The key component of CI is that our quality, patient safety and cost-effectiveness measures are the same across all of the health plans. Our program covers both risk contracts and FFS contracts. Therefore, both health maintenance organization (HMO) and preferred provider organization (PPO) contracts are covered.

    We negotiate both base and incentive compensation for physicians. The key component to drive outcome is that the same measures and thresholds of performance are common across all of these contracts. That allows the providers to overcome what has been referred to as a "Tower of Babel" in the past. Even when different insurance companies had similar measures in their PFP programs, the thresholds and methods to collect and report the data were different. It became so confusing for providers that they were not able to focus on performance improvement. They threw up their hands and said, "Well, let the chips fall where they may."

    By having the common set of measures across all of the payors, we are able to develop tools and common reporting systems to drive change. This is our definition of CI: physicians across specialties working together with hospitals to drive quality, patient safety and cost-effectiveness. Joint contracting is a critical component of CI; it is the key glue to keep the program together. Joint contracting has been a key issue that has engaged APP in discussions with regulators, particularly the Federal Trade Commission (FTC). They have given us approval to continue with this CI program, and that is important for others who are thinking about doing this kind of program. It passes not only market acceptance, but also regulatory acceptance.

    9 Real-Life Success Strategies from Healthcare Case Managers

    June 19th, 2012 by Jackie Lyons

    Accountable care, night shifts and holistic medicine are a few strategies paying off for real-life case managers.

    HIN asked healthcare case managers to share the single most successful strategy their organization has employed. Here is what they had to say:

    Hillary Calderon, RN, Senior Manager of Corporate Case Management for HCA: Focusing on initiatives, quality driven and clinical excellence.

    Linda Conroy, RN, BSN, Clinical Integration Case Manager for Hartford Physician Hospital Organization (HPHO): The HPHO is working with Hartford Hospital to reduce the rate of readmissions for our patients that are discharged with a primary diagnosis of congestive heart failure. We are working with several home care agencies and skilled nursing facilities to provide improved transition of care and education to both family and patient.

    Stacey B. Hodgman, MS, RN-BC, CCDS, CPUM, District Director of Case Management for Kindred Healthcare, Board of Directors for the Case Management Society of New England: We continue to improve our efforts with care coordination and care management as we strategize to become the post-acute care provider of choice for our market areas in the country. We are working with the Pioneer ACOs to identify ways we can help ensure progression of care through the continuum and reduce readmissions. This is an exciting time for us, as it is for our nation, as we embark upon a new healthcare delivery system.

    Barbara King, BSN, RN, Co-Founder and President of NurseValue, Inc.: We provide custom solutions to our clients. Our experience opens the door to complicated case referrals. We then use our understanding of the health system, our knowledge of health, injury and illness, and our collaborative communication process to drive cases to the most successful end point possible. Our clients appreciate the fact that we have developed a successful case management model that combines the telephonic and field case management services in a unique delivery system that provides a cost conscious solution.

    Barbara (Bobbi) Kolonay, RN, BSN, MS, CCM, Owner of Options for Elder Care, Medical Care Management Services for Seniors: We are having tremendous success managing and assuring quality of life with a group of individuals the medical community has given up on - those with a diagnosis of Alzheimer’s disease. Where modern medicine often fails this group, ancient medicine and holistic practices is working!

    Sonia Morrison, RN, CM, BSN, RN case manager at Salinas Valley Memorial Healthcare System (SVMHCS), Nurse Assessment Consultant and Educator for veterans at Visiting Angels of Santa Cruz: Expanding the role of case management to include p.m. shifts.

    Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CEAS II, Founder and President of VP Medical Consulting, LLC: The one thing we do better than most other case management firms has to do with the way in which we approach each case. We have experience in the legal system both within and outside of workers’ compensation. The experience gleaned from working in the legal system means a new way of managing claims. Rather than focusing just on the situation as it stands before us, we are also looking toward the future. It is like a game of chess. Each case decision made now may result in a different outcome and open up new issues which need to be addressed in the future.

    Linda Van Dillen, RN, BA, CCM, Executive VP/Partner of S&H Medical Management Services, Inc.: We have recently worked to update and upgrade our vocational program. Vocational consultants in each of our territories have become certified ergonomic assessment specialists (CEAS.) Our physical demand analyses are very highly regarded and as a result of this upgrade to our services, we have doubled our vocational team in the past couple years!

    Miriam Weiss, MSN, RN, CCM, Care Manager at Amerigroup Corporation, Care Manager Consultant, Per Diem, at CareManagers Inc.: It is moving forward to acquire NCQA recognition in New Jersey.

    For more success strategies, and metrics and measures on current and planned case management initiatives, check out 2012 Healthcare Benchmarks: Case Management, a new 60-page resource from HIN presented in more than 70 easy-to-follow graphs and tables.

    UPMC Home Visits Target Unplanned Care in Emergency Departments

    June 18th, 2012 by Jessica Fornarotto

    UPMC members who treat the ER as a primary care provider can expect a home visit from the health plan's community teams of nurses and social workers. Community teams visit these members at home to perform assessments and care management.

    That's one of the ways UPMC Health Plan is reducing the rates of avoidable emergency room use, according to Debra Smyers, senior director of program development at UPMC, who presented these strategies during a recent webinar on Identifying, Engaging and Breaking Down Patient Barriers To Reduce Avoidable ED Use.

    UPMC developed community teams to engage members who were having “unplanned care” — members who thought of the ER as their own personal PCP. These teams focus primarily on the Medicaid and special needs populations. UPMC sends health plan nurses and social workers into the community to visit the targeted members in their homes. These visits continue for a few months. Then, the nurse or social worker hands the member over to a different caregiver to continue the care.

    UPMC calls it a "real team approach;" they even have nurses located in the patient-centered medical home (PCMH) who can link members to an appropriate caregiver, explains Ms. Smyers. For instance, if the member is a smoker and wants to quit, the nurse would link that member to the lifestyle health coach who helps with smoking cessation.

    UPMC Health Plan has also placed a patient navigator in the ER to educate patients on appropriate ER use. These navigators ask patients coming into the ER for a minor illness, such as for a sore throat, if there are any care alternatives they could use instead, such as visiting their PCP. Should the patient not have a PCP, the navigator will then help the patient to find one.

    Originally, to identify patients using the ER inappropriately, UPMC would go through a monthly stratification process that included data from previous months. However, this identified patients too long after their ER visit, when it was irrelevant to help the patient. The health plan now uses actual registration data from the ERs to find their targeted patients.

    With this new plan, UPMC was then able to reach the patient about their ER use on the actual day of the hospital visit. Also, to have a more direct focus on the different patients that were coming into the ER, UPMC stratified all patients into three targeted groups: those with high ER use, those with ER visits for conditions, and those patients with level 1 or 2 ER visits.

    Smyers also discussed UPMC's Connected Care Program to help improve care coordination for patients with serious mental illnesses. The health plan based this program on the PCMH model of care to address how physical and behavioral healthcare providers can manage the care of this specific population.

    One of the components of this program is integrated care team meetings with staff members to focus on how to support patients with their personal and social needs. For instance, if a patient is constantly going to the ER for an illness only because the ER staff treats them well, the patient needs to understand why that constitutes inappropriate use of the ER.

    This UPMC program engaged 2,500 members over two years.

    In 2010, UPMC added an ER measure to their pay-for-performance (PFP) program. This measure is made up of two parts: one looks at utilization of the ER in comparison to other practices in the PFP program, and the other part looks at the rate of the practice’s improvement from the previous year.

    One of the many outcomes from the ER measure was that in 2011, the PFP practices had a rate of ER visits of 34/1,000 less than the overall performance and 145/1,000 less than the non-PFP practices.