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Community case management outcomes
Guidelines & Outcomes
COMMUNITY CASE MANAGEMENT OUTCOMES by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
C
ommunity case management (CM) is perhaps one of the oldest forms of the profession. Many scholars of CM history say the practice began from the combination of two health care disciplines—public health nursing and social services. Although the roots of CM developed decades ago, today’s practice remains close to the original concept that caring for the chronically ill person in a community setting can increase positive clinical outcomes and decrease costs significantly. One organization at the forefront of this type of health care delivery service is Piedmont Hospital in Atlanta, Ga. Community clinical CM (CCCM), as it is known at Piedmont, is a communitybased model of care that offers holistic management of medically complex, chronically ill, high-risk patients. These individuals often use multiple health systems’ resources and require advanced health assessments and psychosocial support. Often physicians and other caregivers label them “noncompliant” when actually many obstacles prevent them from obtaining and implementing the appropriate care they require. These individuals have an intense need for their complex care to be coordinated across the continuum. Julie Webster, a nurse practitioner with the CCCM program, says, “Piedmont has been involved in CCCM since 1997. CCCM was developed to meet the greater challenges brought about by managed care and the accompanying external forces in the marketplace. In this environment of changing reimbursement methodologies, the coordination of services and resources for the person with complex needs has assumed greater urgency. Given the opportunity to define and strengthen the impact of advanced practice nursing in the care of the chroniTCM 40
July/August 2001
cally ill, high-risk patient, we developed this unique program.” According to Pam Cowart, a clinical nurse specialist, “CCCM occurs within each individual’s lived experience of chronic illness. We recognize that health is the quality of life as that person defines it, and he or she is the expert on his or her own health. We conduct home visits to provide ongoing advanced health assessment, monitoring, and education. Home visits offer a unique and valuable perspective of how a person manages his or her chronic illness.” An integrated network of resources within the hospital supports the CCCM model. These resources include disease management, resource management, clinical pathways, and protocols, as well as community resources. CCCM works in concert with other home care providers when a skilled need is identified. CCCM is a self-directed work team that reports to the director of nursing. Cowart adds, “Care is coordinated through the continuum by a collaborative approach among the advance practice nurse, the physician, and the person receiving care. We often see patients in the physician’s office to promote this collaboration.” CCCM focuses on the patient populations who will benefit the most from the services. Webster says, “Initial identification of patient groups for CCCM were identified by retrospective data of cost, length of stay, and recidivism. The initial two populations that exemplified the best trends for institutional performance efforts were congestive heart failure and chronic obstructive pulmonary disease. Projections of potential cost avoidance on those patients readmitted with the diagnosis of heart failure or COPD were calculated using retrospective financial data from July through December 1996. Inclusion criteria were
TABLE 1. COMMUNITY CLINICAL CASE MANAGEMENT PROGRAM Criteria: chronic or terminal illness with 2 or more of the following risk factors • Multiple hospital, ED, and physician visits • Multiple physician involvement • High cost care • Frailty • Perceived poor health • ADL deficits • IADL deficits that cause significant risk • Multiple system illness • Significant socioeconomic, family, psychosocial, emotional, spiritual needs • High probability for physiological imbalance • Evidence of malnutrition • Polypharmacy
developed to identify the high-risk patients within these populations, as shown in Table 1. To build credibility for the program, physicians in the specialties of cardiology and pulmonology were then enlisted to become partners with the advance practice nurse in the delivery of collaborative clinical care in the CCCM model.” The goals established for CCCM were: • Empower the person and family receiving care by maximizing their self-care capabilities or peaceful death with dignity • Provide early intervention and ongoing management of the person’s health
• Coordinate and negotiate services needed Cowart says, “We use data-driven clinical management reports to evaluate patient care outcomes. In addition to the commonly measured outcomes of cost, length of stay, and recidivism, CCCM measures other quantitative outcomes, including admission acuity, appropriateness of health care access, and matching of the person’s needs with available community services. The CCCM program demonstrated a cost savings of $360,366 for fiscal year 2000. Our performance profiles for CCCM patients show reduced hospital days per patient per months of care in addition to decreased total hospital days and ED visits.” Webster adds, “We measure and report qualitative outcomes that include person centeredness and quality of life, looking at both functional and physiological outcomes and personal satisfaction. Measuring quality of life on an individual basis is achieved through the use of such tools as the Minnesota Living with Heart Failure and the Seattle Obstructive Lung Disease questionnaires. Our physicians and patients both express great satisfaction with the services provided by the CCCM program. Exemplars and patient comments are included in our annual outcome report. “I know we are making a positive difference in the lives of our patients, and there is great satisfaction knowing this.” The advanced practice nurse plays a profoundly stronger role in this program because the physician, advance practice nurse, and person receiving care share responsibility and accountability for outcomes. CCCM is an important focus within our health care system and a time-honored method of improving clinical and cost-effective outcomes. ❑ Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ, is the founder and president of CQI, a health care management consulting services company in San Diego, Calif., specializing in utilization, quality, case, and disease management. She can be reached at (619) 226-4141; Email [email protected]; website www.CQIhealthcare.com. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/117234 doi:10.1067/mcm.2001.117234
July/August 2001
TCM 41
COMMUNITY CASE MANAGEMENT OUTCOMES by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
C
ommunity case management (CM) is perhaps one of the oldest forms of the profession. Many scholars of CM history say the practice began from the combination of two health care disciplines—public health nursing and social services. Although the roots of CM developed decades ago, today’s practice remains close to the original concept that caring for the chronically ill person in a community setting can increase positive clinical outcomes and decrease costs significantly. One organization at the forefront of this type of health care delivery service is Piedmont Hospital in Atlanta, Ga. Community clinical CM (CCCM), as it is known at Piedmont, is a communitybased model of care that offers holistic management of medically complex, chronically ill, high-risk patients. These individuals often use multiple health systems’ resources and require advanced health assessments and psychosocial support. Often physicians and other caregivers label them “noncompliant” when actually many obstacles prevent them from obtaining and implementing the appropriate care they require. These individuals have an intense need for their complex care to be coordinated across the continuum. Julie Webster, a nurse practitioner with the CCCM program, says, “Piedmont has been involved in CCCM since 1997. CCCM was developed to meet the greater challenges brought about by managed care and the accompanying external forces in the marketplace. In this environment of changing reimbursement methodologies, the coordination of services and resources for the person with complex needs has assumed greater urgency. Given the opportunity to define and strengthen the impact of advanced practice nursing in the care of the chroniTCM 40
July/August 2001
cally ill, high-risk patient, we developed this unique program.” According to Pam Cowart, a clinical nurse specialist, “CCCM occurs within each individual’s lived experience of chronic illness. We recognize that health is the quality of life as that person defines it, and he or she is the expert on his or her own health. We conduct home visits to provide ongoing advanced health assessment, monitoring, and education. Home visits offer a unique and valuable perspective of how a person manages his or her chronic illness.” An integrated network of resources within the hospital supports the CCCM model. These resources include disease management, resource management, clinical pathways, and protocols, as well as community resources. CCCM works in concert with other home care providers when a skilled need is identified. CCCM is a self-directed work team that reports to the director of nursing. Cowart adds, “Care is coordinated through the continuum by a collaborative approach among the advance practice nurse, the physician, and the person receiving care. We often see patients in the physician’s office to promote this collaboration.” CCCM focuses on the patient populations who will benefit the most from the services. Webster says, “Initial identification of patient groups for CCCM were identified by retrospective data of cost, length of stay, and recidivism. The initial two populations that exemplified the best trends for institutional performance efforts were congestive heart failure and chronic obstructive pulmonary disease. Projections of potential cost avoidance on those patients readmitted with the diagnosis of heart failure or COPD were calculated using retrospective financial data from July through December 1996. Inclusion criteria were
TABLE 1. COMMUNITY CLINICAL CASE MANAGEMENT PROGRAM Criteria: chronic or terminal illness with 2 or more of the following risk factors • Multiple hospital, ED, and physician visits • Multiple physician involvement • High cost care • Frailty • Perceived poor health • ADL deficits • IADL deficits that cause significant risk • Multiple system illness • Significant socioeconomic, family, psychosocial, emotional, spiritual needs • High probability for physiological imbalance • Evidence of malnutrition • Polypharmacy
developed to identify the high-risk patients within these populations, as shown in Table 1. To build credibility for the program, physicians in the specialties of cardiology and pulmonology were then enlisted to become partners with the advance practice nurse in the delivery of collaborative clinical care in the CCCM model.” The goals established for CCCM were: • Empower the person and family receiving care by maximizing their self-care capabilities or peaceful death with dignity • Provide early intervention and ongoing management of the person’s health
• Coordinate and negotiate services needed Cowart says, “We use data-driven clinical management reports to evaluate patient care outcomes. In addition to the commonly measured outcomes of cost, length of stay, and recidivism, CCCM measures other quantitative outcomes, including admission acuity, appropriateness of health care access, and matching of the person’s needs with available community services. The CCCM program demonstrated a cost savings of $360,366 for fiscal year 2000. Our performance profiles for CCCM patients show reduced hospital days per patient per months of care in addition to decreased total hospital days and ED visits.” Webster adds, “We measure and report qualitative outcomes that include person centeredness and quality of life, looking at both functional and physiological outcomes and personal satisfaction. Measuring quality of life on an individual basis is achieved through the use of such tools as the Minnesota Living with Heart Failure and the Seattle Obstructive Lung Disease questionnaires. Our physicians and patients both express great satisfaction with the services provided by the CCCM program. Exemplars and patient comments are included in our annual outcome report. “I know we are making a positive difference in the lives of our patients, and there is great satisfaction knowing this.” The advanced practice nurse plays a profoundly stronger role in this program because the physician, advance practice nurse, and person receiving care share responsibility and accountability for outcomes. CCCM is an important focus within our health care system and a time-honored method of improving clinical and cost-effective outcomes. ❑ Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ, is the founder and president of CQI, a health care management consulting services company in San Diego, Calif., specializing in utilization, quality, case, and disease management. She can be reached at (619) 226-4141; Email [email protected]; website www.CQIhealthcare.com. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/117234 doi:10.1067/mcm.2001.117234
July/August 2001
TCM 41