Healthcare Intelligence Network

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.”