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Acute Care Innovations and Outcomes in the Military Medical System
Guidelines & Outcomes
ACUTE CARE INNOVATIONS AND OUTCOMES IN THE MILITARY MEDICAL SYSTEM by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
A
cute care is one of the foundation areas of case management (CM). As managed care, federal budgeting principles, and regulatory pressures have increased the focus on cost-effective, quality care, CM has become an expected part of the health care services provided by acute care organizations. Speak with almost any CM director and she will say it has become more important than ever to prove CM outcomes. The arena of focus has changed, too, as the regulations require more CM involvement in promoting the continuum of care. One arena gaining significant momentum is CM in the military treatment system (MTS), which is focusing on identifying those patients who need CM services and improving health care services through a variety of models. As in the civilian health care sector, the MTS has come under federal budgeting pressure to manage its limited financial resources more effectively and, at the same time, fulfill the mission of improved quality of care for the individuals served. Linda Brown, CM consultant for the Navy Bureau of Medicine and Surgery and facilitator for the Case Management Society of America’s Military Special Interest Group, says, “We are very excited about the development of CM in the military. When I first started working with CM in 1988, our program focused on the 2% of the health care population who consumed 52% of the benefit dollars. This early CM model was episodic and focused on acute admissions. We rarely were permitted to follow patients across the continuum of care. The military reimbursement structure for health care services was similar to the civilian sector fee-for-service basis. Claims history data under a fee-for-service structure allowed us to match cost savings to CM TCM 32
July/August 2000
services. When the DRG system was implemented, it became more difficult to correlate cost savings to CM services. Reimbursements for outpatient services were capped as well, creating even more difficulties in correlating cost savings attributable to CM activities. But the implementation of TRICARE has changed her situation, Brown said. “We now work in a capitated environment in which military hospitals and managed care support contractors receive a fixed amount of money for TRICARE Prime enrollees. Financing has become much more complicated, making it very difficult to demonstrate cost savings. We are looking at CM software as a possible solution to help identify cost savings and monitor and track clinical outcomes. I try not to sell CM to commanding officers exclusively as a costsavings tool—certainly money can be saved in the aggregate, but administrative costs associated with CM are high, particularly in the start-up phase. She continues, “In the meantime, we continue to focus on improved clinical outcomes. As military hospitals fell under DRGs and shorter lengths of stay, it became obvious that discharge plans with patient-specific goals were critical to ensure positive clinical outcomes for patients who were being sent home sicker. It is imperative to have a case manager follow up with patients at home to check on their progress, prevent complications, and ensure as full a recovery as possible. “Another area of focus with the department is the Exceptional Family Member Program and the Program for Persons with Disabilities. These programs provide services to families that have members with chronic medical problems and disabilities. When the military family is moved, we try to ensure that the services the member needs are available in a new
Resources Linda Brown, CM Consultant Navy Bureau of Medicine and Surgery (202) 762-3137 [email protected] Capt. Lyle Melton, Pediatric Case Manager Navy Medical Center, San Diego (619) 532-5201 [email protected] Capt. Melanie Prince, Chief HealthCare Integration OIC, Nurse Managed Clinic Hill Air Force Base (801) 777-6623 [email protected] location. Many patients have severe chronic illnesses that require specialized services and medical treatment to be readily available for the individual and family. The system has been fragmented in the past, but there are moves underway to ensure that military families who have members with special needs are assigned to a case manager who can be an advocate for that family, particularly when they transfer from one part of the world to another. “It is not uncommon for a military family to move 17 times over the course of their active duty military career. These families need help upfront to make sure they are being assigned to a location where their medical needs can be met and have treatment plans in place by the time the family arrives at their new duty location. The best outcome in this situation is that the families can be well taken care of and the military service member is able to concentrate on their new work assignment.” Capt. Lyle Melton, case manager for Naval Medical Center in San Diego, says,
GUIDELINES & OUTCOMES “We have many exciting CM initiatives underway. For example, a fibromyalgia group was started as a way to manage the considerable utilization of resources by these patients. A study 6 months after the initiation of the group showed a decrease in hospital admissions and ED visits. While the clinic visits increased, they were much more appropriate, and there was a dramatic decrease in telephone calls to the providers for nonurgent issues.
disease, which can cause individuals to incur inpatient costs if not managed well on an outpatient basis.
He continues, “CM at the Naval Medical Center began in 1998 after a pilot project showed that program was cost-effective and improved patient and provider satisfaction. Four CM teams composed of social work and nurse case managers follow patients through the continuum of care, both in the inpatient and outpatient setting. Two of our teams are involved in the TRICARE Senior Prime program for Medicare-eligible military retirees. The third team is responsible for the pediatric population, while the fourth works with active duty members with catastrophic conditions. Although this project is in its early stages of development, initial studies suggest that CM has improved the coordination of care at the Naval Medical Center.”
Capt. Prince says, “We looked at the number and type of appointments our patients were scheduling in our clinics and realized the data indicated there were many patients with chronic diseases who were not getting better. While we did have patients who were scheduling for acute or urgent appointments in our outpatient clinics, our data indicated a large preponderance of patients returning frequently for appointments pertaining to chronic ailments. Our goal was to implement a CM system that would reduce the utilization of services for chronic appointments, improve the management of care based on accepted clinical guidelines, and concentrate CM services on education, monitoring, and self-management through a series of prescribed clinical paths, clinical data management, and CM interventions. If the individual requires acute care services, we coordinate with the TRICARE contractor to follow the patient in the inpatient environment. However, one of our goals is to better manage the outpatient care to prevent inpatient services where appropriate.”
Capt. Melanie Prince with the U.S. Air Force also has developed an innovative CM program—a stand-alone, nursemanaged clinic staffed by four nurse case managers. The clinic has been in operation for 3 years serving active duty personnel and their family members. The focus of the CM program is on chronic
Acute care CM has become an important part of the challenging and complex national health care delivery system. As we implement even more innovative services, proving value through outcomes will benefit us all—case managers, patients, and the members of military health systems. ❑
Author’s note: The views expressed in this article are those of the author and her sources and do not necessarily reflect the views of the departments of the Navy, Air Force, or Defense nor the U.S. government. 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; E-mail [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. 68/1/109134 doi:10.1067/mcm.2000.109134
July/August 2000
TCM 33
ACUTE CARE INNOVATIONS AND OUTCOMES IN THE MILITARY MEDICAL SYSTEM by Julia A. Rieve, RN, BSHCM, CCM, CPHQ, FNAHQ
A
cute care is one of the foundation areas of case management (CM). As managed care, federal budgeting principles, and regulatory pressures have increased the focus on cost-effective, quality care, CM has become an expected part of the health care services provided by acute care organizations. Speak with almost any CM director and she will say it has become more important than ever to prove CM outcomes. The arena of focus has changed, too, as the regulations require more CM involvement in promoting the continuum of care. One arena gaining significant momentum is CM in the military treatment system (MTS), which is focusing on identifying those patients who need CM services and improving health care services through a variety of models. As in the civilian health care sector, the MTS has come under federal budgeting pressure to manage its limited financial resources more effectively and, at the same time, fulfill the mission of improved quality of care for the individuals served. Linda Brown, CM consultant for the Navy Bureau of Medicine and Surgery and facilitator for the Case Management Society of America’s Military Special Interest Group, says, “We are very excited about the development of CM in the military. When I first started working with CM in 1988, our program focused on the 2% of the health care population who consumed 52% of the benefit dollars. This early CM model was episodic and focused on acute admissions. We rarely were permitted to follow patients across the continuum of care. The military reimbursement structure for health care services was similar to the civilian sector fee-for-service basis. Claims history data under a fee-for-service structure allowed us to match cost savings to CM TCM 32
July/August 2000
services. When the DRG system was implemented, it became more difficult to correlate cost savings to CM services. Reimbursements for outpatient services were capped as well, creating even more difficulties in correlating cost savings attributable to CM activities. But the implementation of TRICARE has changed her situation, Brown said. “We now work in a capitated environment in which military hospitals and managed care support contractors receive a fixed amount of money for TRICARE Prime enrollees. Financing has become much more complicated, making it very difficult to demonstrate cost savings. We are looking at CM software as a possible solution to help identify cost savings and monitor and track clinical outcomes. I try not to sell CM to commanding officers exclusively as a costsavings tool—certainly money can be saved in the aggregate, but administrative costs associated with CM are high, particularly in the start-up phase. She continues, “In the meantime, we continue to focus on improved clinical outcomes. As military hospitals fell under DRGs and shorter lengths of stay, it became obvious that discharge plans with patient-specific goals were critical to ensure positive clinical outcomes for patients who were being sent home sicker. It is imperative to have a case manager follow up with patients at home to check on their progress, prevent complications, and ensure as full a recovery as possible. “Another area of focus with the department is the Exceptional Family Member Program and the Program for Persons with Disabilities. These programs provide services to families that have members with chronic medical problems and disabilities. When the military family is moved, we try to ensure that the services the member needs are available in a new
Resources Linda Brown, CM Consultant Navy Bureau of Medicine and Surgery (202) 762-3137 [email protected] Capt. Lyle Melton, Pediatric Case Manager Navy Medical Center, San Diego (619) 532-5201 [email protected] Capt. Melanie Prince, Chief HealthCare Integration OIC, Nurse Managed Clinic Hill Air Force Base (801) 777-6623 [email protected] location. Many patients have severe chronic illnesses that require specialized services and medical treatment to be readily available for the individual and family. The system has been fragmented in the past, but there are moves underway to ensure that military families who have members with special needs are assigned to a case manager who can be an advocate for that family, particularly when they transfer from one part of the world to another. “It is not uncommon for a military family to move 17 times over the course of their active duty military career. These families need help upfront to make sure they are being assigned to a location where their medical needs can be met and have treatment plans in place by the time the family arrives at their new duty location. The best outcome in this situation is that the families can be well taken care of and the military service member is able to concentrate on their new work assignment.” Capt. Lyle Melton, case manager for Naval Medical Center in San Diego, says,
GUIDELINES & OUTCOMES “We have many exciting CM initiatives underway. For example, a fibromyalgia group was started as a way to manage the considerable utilization of resources by these patients. A study 6 months after the initiation of the group showed a decrease in hospital admissions and ED visits. While the clinic visits increased, they were much more appropriate, and there was a dramatic decrease in telephone calls to the providers for nonurgent issues.
disease, which can cause individuals to incur inpatient costs if not managed well on an outpatient basis.
He continues, “CM at the Naval Medical Center began in 1998 after a pilot project showed that program was cost-effective and improved patient and provider satisfaction. Four CM teams composed of social work and nurse case managers follow patients through the continuum of care, both in the inpatient and outpatient setting. Two of our teams are involved in the TRICARE Senior Prime program for Medicare-eligible military retirees. The third team is responsible for the pediatric population, while the fourth works with active duty members with catastrophic conditions. Although this project is in its early stages of development, initial studies suggest that CM has improved the coordination of care at the Naval Medical Center.”
Capt. Prince says, “We looked at the number and type of appointments our patients were scheduling in our clinics and realized the data indicated there were many patients with chronic diseases who were not getting better. While we did have patients who were scheduling for acute or urgent appointments in our outpatient clinics, our data indicated a large preponderance of patients returning frequently for appointments pertaining to chronic ailments. Our goal was to implement a CM system that would reduce the utilization of services for chronic appointments, improve the management of care based on accepted clinical guidelines, and concentrate CM services on education, monitoring, and self-management through a series of prescribed clinical paths, clinical data management, and CM interventions. If the individual requires acute care services, we coordinate with the TRICARE contractor to follow the patient in the inpatient environment. However, one of our goals is to better manage the outpatient care to prevent inpatient services where appropriate.”
Capt. Melanie Prince with the U.S. Air Force also has developed an innovative CM program—a stand-alone, nursemanaged clinic staffed by four nurse case managers. The clinic has been in operation for 3 years serving active duty personnel and their family members. The focus of the CM program is on chronic
Acute care CM has become an important part of the challenging and complex national health care delivery system. As we implement even more innovative services, proving value through outcomes will benefit us all—case managers, patients, and the members of military health systems. ❑
Author’s note: The views expressed in this article are those of the author and her sources and do not necessarily reflect the views of the departments of the Navy, Air Force, or Defense nor the U.S. government. 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; E-mail [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. 68/1/109134 doi:10.1067/mcm.2000.109134
July/August 2000
TCM 33