Posts Tagged ‘Embedded Case Management’

2 Essential Steps for Embedding Case Managers

April 24th, 2014 by Cheryl Miller

Selecting the right practice for embedded case managers, and then getting physicians to embrace the concept, are key to successfully embedding case managers, say two thought leaders, Irene Zolotorofe, RN, MS, MSN, administrative director of clinical operations at Bon Secours Health System, and Randall Krakauer, MD, national Medicare medical director for Aetna. Here, they discuss how to best implement these steps.

Question: How did you select practices for embedding of case managers, and what were the first steps in preparing the practice?

Response: (Irene Zolotorofe) They were chosen primarily at the recommendation of some of our operations directors; also, we began with the physicians who are absolutely willing to go ‘medical home,’ that are excited about this model of care. We like to go into a practice where they are motivated to do that type of transition with their patient population.

Physicians are the key; as a physician group expresses interest, we work with them first, since they are key to getting a whole team going. We work hand in hand with the physicians and then the practice managers, and then we bring the process down to the rest of the staff. It takes us about three months.

Question: What marketing strategy is employed to encourage the physician groups to collaborate and embrace the concept of embedding health plan case managers in their practices?

Response: (Dr. Randall Krakauer) What doesn’t always work well is to start with ‘I’m here to help you.’ It is a matter of meeting with your physicians and discussing some of your mutual goals and mutual interests. We focus on those aspects of the equation in which we have common interests: quality of care, doing a better job for our members, your patients. We focus on areas in which we have the opportunity to work together. We show them what we have accomplished in the areas of care management on our own. We can show them at this point, since we’re not new to the game now, some results that we have achieved with other physician partners. And we initiate a discussion on how we can support each other, how we can work together to meet our mutual goals and how we can both benefit from this process.

And with a little bit of time and effort in a great many cases, some great things can happen as a result of such discussions.

Excerpted from Essentials of Embedded Case Management: Hiring, Training, Caseloads and Technology for Practice-Based Care Coordinators.

How Taconic IPA Embedded Case Managers Risk-Stratify High-Risk, High-Cost Patients

November 5th, 2013 by Jessica Fornarotto

Using a self-developed approach that combines elements of Geisinger’s Proven Health® Navigator, Johns Hopkins Guided Care Nursing and the Wagner Chronic Care Model, Taconic Professional Resources is assisting physician practices in the New York Hudson Valley to improve population health and care for their sickest patients through the use of embedded RN case managers.

During HIN’s webinar on Improving Population Health With Embedded Case Managers in an Open, Multi-Payor Community, Annette Watson, senior vice president of community transformation for Taconic, described how case managers identify high-risk, high-cost patients.

How does a case manager go in and identify who is high-risk or who is high-cost? You can do it a number of ways, and they can be formal and informal. You can use internal sources and when we do go in, that’s one of the baselines you have to understand. Who are the patients and what is the population? If they have not been using data or have not been in an Advanced Primary Care initiative, it’s highly unlikely that a practice has a quantitative method in place when we arrive.

We begin by asking the practice providers who are the sickest patients? We can then use data that’s available at the practice level, such as registries or reports, that can be run from the EHR. We also look at what kind of data they’re getting from external sources. Are they getting reports from payors that perhaps show some utilization activity?

One thing about many of those reports is that they may be somewhat aged. They’re not necessarily timely, which creates actionable questionability. But we’re finding more and more reports about recent ER use or discharges from payors that are more and more timely that allow the practices to look at data retrospectively in most cases, but much more quickly than they were getting in the past.

And when it comes to hospital admission and discharge information, many times in a primary care practice depending on the model, if they are not the admitting physician, whether it’s a specialist or a hospitalist or someone that comes through the ER, it’s not a given. People think they know about their patients being in the hospital. They don’t always, and that is a challenge and a workflow implementation that we often spend a lot of time on when we get into a practice — how to get the timely information about admissions and discharges.

We also implement new processes in the practice to formally assess the risk of patients using validated tools. In the Hudson Valley, the tool that was easily adopted and modified in a variety of EHR’s is from the American Academy of Family Physicians (AAFP). This tool allows for a quantifiable way to put a risk level on every patient in a practice who is seen, and it changes over time. It’s the kind of tool that when a case manager goes into a practice, we look at risk stratification as an important characteristic of identifying those patients and managing those patients over time.

Embedding Case Managers as Ambassadors of Advanced Primary Care

October 18th, 2013 by Cheryl Miller

Embedded case managers are carefully being groomed as ambassadors for the evolving patient-centered healthcare landscape, a perspective that seeks to achieve the Triple Aim objectives of better care, experience and cost.

And while challenges to employing embedded case managers persist, including staff buy-in and communication, reimbursement is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), a participant in CMS Innovation Center’s Comprehensive Primary Care (CPC) initiative. TIPA helps physician practices in New York’s Hudson Valley to improve population health and care for their sickest patients with the use of embedded RN case managers. Watson shared TIPA’s deployment strategy during an October 9, 2013 webinar, Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community.

One of the first steps is finding case managers with the right combination of education, experience and attitude, says Watson. The immediate past chair of the Commission for Case Manager Certification, she has served as a commissioner since 2007. They must meet strict requirements, including having either the Commission for Case Management Certification (CCMC) or RN board-certified designation from the American Nurses Credentialing Center (ANCC). Both of those organizations have mandatory continuing education requirements around case management, important because case managers must be current clinically in order to meet the ever changing field of disease management, and be effective in dealing with either the chronically ill, or those with complex comorbidities.

Embedded case managers must also be ready to address such issues as redesigning workflows and conducting risk stratifications. These issues tend to be obstacles to effective management of patient panels, so case managers with that skill set are highly valued, she explained.

Once deployed, the embedded case manager assumes various roles in physician practices, from supporting the CPC to meeting accountable care organization (ACO) and patient-centered medical home (PCMH) requirements. The Medicare ACO measures and specifications talk specifically about care coordination and patient safety activities, Watson says. Within Comprehensive Primary Care, there are requirements and milestones around managing their high-risk patients and active engagement and care coordination across medical neighborhoods.

Watson also shared effective ways to use electronic medical records (EMRs), patient registries, payor data and other tools within a practice to support the embedded case manager.

But one of the final frontiers might be physician buy-in, Watson says. One of the ways to get physicians on board is when initially implementing the case manager into the practice. Getting just one physician champion in the practice to help with the change is key to the overall success of embedding case managers.

Annette Watson talks more about embedding case managers in an open multi-payor community in this Healthcare Intelligence Network webinar.

10 Considerations When Preparing a Practice for the Embedded Case Manager

September 20th, 2012 by Cheryl Miller

Embedded case management

Practice-based case management is driving improvements in healthcare delivery and efficiency.


As practice-based case management continues to grow, resulting in more efficient and high quality care coordination of high-risk patients and chronically ill health plan members, one question looms large: how does a practice determine if it’s ready to take the leap?

We asked our case management experts for their opinions, and found that while there was no ‘one-size fits all’ method, many considerations were considered essential to a successful ECM practice.

  1. Find the right practice.

    Are your head physicians proponents of the medical home model? Because you don’t want to put efforts into a group that isn’t interested in embracing a new model of care. Says Irene Zolotorofe, administrative director of clinical operations at Bon Secours, “We began with the physicians who were absolutely willing to go ‘medical home,’ who were excited about this model of care. We like to go into a practice where they are motivated to do that type of transition with their patient population.”

  2. Involve all members of the practice in the selection process.

    Getting all members involved in selecting the case manager is key to sustaining a successful transition, says Diane Littlewood, RN, BSN, CDE, regional manager of case management for health services at Geisinger Health Plan. “We found great value incorporating and including the primary care doctor, the site and the team in the selection process. That case manager is embedded; she’s part of their team and that’s where she spends 100 percent of her time. It is key to each site’s success that the provider be involved with the selection. With this model, we’ve brought the provider at the medical home sites into the process and said, “Sit down with us, interview the candidates and help us with the final selection.’ “

  3. Assemble case manager hiring criteria.

    Although experience, education and training is important in this role, they should not be the main selection criteria, says Zolotorofe. “Is the case manager able to think quickly and critically given the newness and lack of infrastructure in place for this new program?” Other criteria for choosing a solid case manager included strong communication skills, people skills, patient engagement and activation skills, and negotiating and conflict resolution skills.

  4. Determine how much control your practice will have over your case manager’s work.

    Keeping everyone in the loop fosters an atmosphere of collaboration, says Littlewood. “As you roll out your model and educate providers and staff, you have to explain the case manager’s role and educate the site as to her duties.”

  5. Spend time building strong relationships among group members.

    Once the case manager is part of the team, it’s important that she sustains good relationships with all, says Dr. Randall Krakauer, Aetna’s Medicare medical director, during a recent HIN webinar: “You need to work out an arrangement in each case that works best for this particular medical or provider group. They’re all going to be somewhat difernt and it’s going to be up to your own management and your own embedded case managers to work out how best to work with this particular group, how best to support this group and how best to relate to this group. That relationship is absolutely key. The case manager and your staff must build a good supportive relationship. Your case manager has to feel to them like their case manager.”

  6. Allow case managers to build strong relationships with their patients, and provide tools to facilitate this.

    Geisinger Health Plan implemented a direct telephone line to embedded case managers for all patients, says Littlewood. “As simple and basic as it sounds, the ability for our case managers to have a direct line at the site for patients makes a difference. All the patient has to do is pick up a telephone, say hello and they will have a case manager on the phone. They’re not trying to navigate through the complex telephone lines as they call in to the clinic sites, which could be confusing for the patient. This is a direct access phone line. The case manager does the assessment and collects the information, and then the patient meets with the provider. This process takes out all of the middle people and we’re able to then handle acute issues much sooner. Since the nurse case manager is embedded in the site, she can walk right down the hallway and have a personal conversation with the provider about the person on the phone and their problem or issue. That leads to success with our communication.”

  7. Ensure you have the proper IT tools on hand for an effective program.

    Is there a minimum IT requirement for practices to participate in a practice-based case program, such as a patient registry or EMR? Explains Dr. Krakauer: We do have participating practices that don’t have EMR’s. An EMR will facilitate the process and will make collaborative care management and the work of the participating physicians easier. I don’t think it’s a requirement that there be an EHR. Going forward, as we start getting into more and more information exchanges and more and more reporting requirements promulgated by others, for sizeable groups doing this type of work, increasingly an EHR will be important.

  8. Make sure that your practice has enough eligible patients and the right case mix.

    It’s essential to consider both patient population and eligibility in the beginning, says Charlene Schlude, director of case management at CDPHP. “First, we consider the case mix in a practice. We use a predictive modeling tool that allows us to see the chronic nature of the patients in the practice. We like to see what products they have: is there a higher ratio of Medicare and Medicaid or even chronically ill commercial members in the practice? We use some reporting to do that. Another key element is an EMR in the practice because we want to be efficient and have information at the nurses’ fingertips to make this a valuable experience. We want them to have enough information to interact with the patients in a practice in a way that is going to impact that cost and quality.”

  9. Establish how the case manager will be reimbursed.

    Having a mutually agreed upon reimbursement plan is key to the program’s success, explains Dr. Krakauer. “Normally Aetna will provide this resource; we will provide our own trained experienced case manager who is capable of doing everything. Under certain circumstances, when the medical group already has case managers that are doing a good job, and knows how to do it, some assistance in this regard might be in order. But case management is a specialty in its own right. It’s not something you just hire a nurse to do — have her read a manual and put her at the desk or on the telephone. That’s kind of a prescription for it not to work.”

  10. Determine how you will judge the program’s effectiveness.

    Says Dr. Krakauer: “If I were to pick one single characteristic that’s positive of a good result, I would say it’s the level of commitment of the participating physicians to the concept, to the collaboration and to the idea that doing better will get good results, as opposed to those told to do it as a part of their job or those doing it just to receive an incentive payment.”