CDPHP Makes a Business Case for Embedded Case Managers

Friday, September 23rd, 2011
This post was written by Cheryl Miller

Three years ago primary care was in crisis, says Lisa Sasko, director of clinical transformation for CDPHP. There was a projected shortage of primary care physicians, due in part to a less than competitive earning potential, which was keeping physicians and graduating medical students at bay.

So CDPHP, a not-for-profit, physician-founded and guided health plan that has more than 350,000 members, designed a unique model that would provide enhanced reimbursement for current PCPs, and make it more attractive to medical students and health providers.

That enhanced primary care model was the subject of the Healthcare Intelligence Network’s (HIN) recent webinar The Role of Embedded Case Managers in Clinical Transformation. Together with Charlene Schlude, director of case management at CDPHP, Sasko described the evolution of their model, which incorporated a blend of payment reform and practice transformation, and also shared the following:

  • The operational and cultural issues critical to the success of the program
  • Results from the two-year analysis of the program
  • Planned enhancements of the initiative
  • Business reasons for developing an embedded case management program
  • The day-to-day interactions of embedded case managers with providers in a practice
  • CDPHP’s payment reform strategy uses a risk adjusted base capitation payment, plus bonus opportunities aligned with IHI’s Triple Aim initiative, so that patient satisfaction, quality of care, and cost effectiveness were targets for rewards.

    CDPHP also “retooled the operations of the primary care practice,” said Sasko, focusing on care coordination, leadership development, team care, improved access and population management, with the goal of realizing NCQA Level II medical home certification. To achieve this, they integrated their resources, specifically case management, disease management, behavioral health, pharmacy reporting, and discharge notification.

    Fundamental to the overhaul was embedding case managers in the physician practice, said Schlude.

    “The fundamental concept of case management is that when individuals with complex diseases maintain optimum levels of health and functional capability, everyone benefits: the patients, their support systems, caregivers, healthcare delivery systems and payors. Embedded case managers are indicative of a new era of healthcare in which payors, providers and patients work together in partnership.”

    To be most effective, case managers should have access to EMRs, physician support, aligned goals and be able to interact with patients face-to-face on a consistent basis, Schlude continued. Practices for embedded case management should have willing physicians, and the opportunity to improve quality metrics, and have strong stratification and prioritization techniques in place. Reducing avoidable hospital admissions, and empowering patients to successfully self manage their disease conditions and communicate effectively with their case managers and physicians were key objectives for the embedded case managers.

    Currently one RN covers two enhanced primary care practices two times a week, Schlude said. There is a high focus on Medicaid and Medicare patients, direct documentation in EMRs, and face-to-face introductions with telephonic follow ups.

    Case managers can play significant roles with diabetic patients, the frail elderly, comorbid chronic patients, and end stage renal failure disease (ESRD) patients; ESRD patients in particular consume a disproportionate amount of financial and healthcare resources. In all cases, Schlude said, embedded case managers can help to reduce hospitalizations and costs, and improve quality of life.

    The size of the practice doesn’t matter, Schlude emphasized. Instead, to successfully embed case managers in a clinical practice, it is important to sustain ongoing communication among all, select a case manager that is a “good fit” in the practice, and maintain flexibility and an ability to modify the program model as needed.

    For more information, watch our video Embedded Case Managers in Healthcare:

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