- Email: [email protected]
The economic impact of case management
The Economic Impact of Case Management
C
Ann Markle, BSN, RN-C
ase management (CM) was initiated to manage resource utilization. With demonstrated success,
it was incorporated into acute care settings. As continued effectiveness was demonstrated, CM strategies were used in a variety of settings and with more populations and conditions. Today, it can be seen in a multitude of applications.
TCM 54
July/August 2004
This article demonstrates how CM can improve the health of our society and have a positive economic impact on our health care system. This strategy is instrumental in the coordination of fragmented services and the marshaling of health care resources. This article also describes evidence that supports the use of CM to control health care costs. OVERVIEW OF CURRENT APPLICATIONS Regardless of setting, a case manager looks at a variety of paths, solicits the most appropriate plan, and coordinates the support and expertise of other professionals, agencies, vendors, and family members. Managed Care Plans CM is not synonymous with managed care. The managed care system pairs a provider and patient and strives to man-
age costs, access, and quality of health care delivery. The Health Maintenance Organization Act, established in the early 1970s, started the growth of managed care programs. The health maintenance organization and preferred provider organization are both examples that seek to deter costly inpatient care through preventive and outpatient services. CM is used in these managed care plans as a cost-containment initiative.1 The general mission statement of a managed care organization is to provide quality health care for members while controlling costs. In this setting, case managers regulate access to specialists and services by necessitating medical justification for authorization. Patients with a high utilization of services, multiple chronic conditions, or a catastrophic illness may be targeted. The case manager then develops a plan of care and monitors the patient’s access to care, compliance, and results of the care provided. The case manager helps coordinate care for the client to achieve quality outcomes while demonstrating costeffectiveness.2 Home Health Care Most patients admitted to a hospital are discharged directly to home. With the aging of our society and the fact that people are living longer with chronic medical conditions, many people need home care services on either a temporary or permanent basis. The case manager plays a vital role in the coordination of these services. The acuity level of patients returning home has increased. Many treatments that were once provided only in hospitals can be done at home with proper support. The case manager works with the family, suppliers of durable medical equipment, and ancillary services, such as physical, occupational, and respiratory therapy. The case manager is responsible for ensuring complete home care staffing, visiting the patient as necessitated by the care plan, and serving as the contact person for problems. Problem identification in home care is a continual process, and resolution requires a collaborative effort among nursing and ancillary staff, physicians, family, and patient. The goal is to use allocated
resources in the most cost-effective way in a constantly changing environment.3 Rehabilitation Facility A rehabilitation facility treats cognitive and neuromuscular impairment and seeks to restore people with physical disability to their highest levels of functioning. The goal is to return the patient to an independent lifestyle. Many facilities today specialize in traumatic brain injuries, amputations, or spinal cord injuries.
Case managers regulate access to specialists and services by necessitating medical justification for authorization. The case manager in this setting must have specialized knowledge related to her client population. There is an interdisciplinary team dedicated to the care of the client. The case manager coordinates this team and ensures all necessary consults are obtained. Often the client is a young adult who is healthy but injured. Discharge planning is a major part of this CM role. The case manager is the liaison among team members and must collaborate with the insurance provider, equipment suppliers, home care managers, and physicians. The goal is for the patient to be assimilated back into society as a functioning member.3 Worker’s Compensation Worker’s compensation is another common CM setting. Regulations fall under the policy of the state in which they are written. These cases may be complex and involve collaboration with the claimant, employee insurance carrier, physician, and state worker’s compensation commission. The case manager coordinates all involved parties to achieve optimum health of the client
and timely return to the workforce. The case manager must possess extensive knowledge of regulations in all the states they serve.4 Hospital As discussed, the term CM means different things in different settings of the health care delivery system. The nurse case manager in a hospital manages access to care, coordinates its delivery, and strives for quality, cost-effective outcomes. CM is an approach and organizational attitude used to achieve those ends. A successful program requires administrative commitment, medical staff leadership, and physician accountability. Decreasing length of stay in the hospital is often the first assignment given to case managers. Patterns of prolonged length of stay can indicate complications or slow decision-making. Case managers must look at variances that increase length of stay and see what can be done to eliminate them.5 The first step in problem solving is to identify the problem. With the use of critical pathways, variances are analyzed to help identify the problem. The critical pathway describes special outcomes that must occur within a specified time frame. If the outcome is not completed by the projected time, a variance occurs.3 The CM department may be charged with the task of developing critical pathways in an effort to decrease length of stay. For example, the targeted length of stay for a patient undergoing a total knee replacement is 5 days. The case manager analyzes goals each day to see what was met or not met. She may find that there was no physical therapy service available on Sunday, so the patient did not receive it. Therapy was not done on postoperative day 4, and the patient felt too weak to go home on postoperative day 5 because he did not complete the expected course of therapy. The problem is identified. The case manager can bring this information to hospital administration and review options to eliminate this variance. Perhaps the scheduled operating day for the elective joint patients should be changed to accommodate a lack of weekend July/August 2004
TCM 55
dropped 24.7% and the hospitalization rate for those patients dropped 48%. The case managers screen patients and target populations who are at risk for major health problems. The clients picked for CM are not based on financial cost or disease but for their potential for acute care. The case managers help the members overcome any obstacles to obtaining care and achieving goals.6
Both patients and employers prefer preventive services to treatment of complications. scheduling. Another option may be to look at staffing for physical therapy for weekends. The cost of increasing the frequency of an ancillary service may be less than the addition of 1 hospital day to the length of stay. The case manager in the hospital setting revises every patient’s care every day. Interdisciplinary rounds are conducted to assess a patient’s response to treatment. The case manager organizes the team’s efforts to move a patient and family toward a desired goal. This team approach holds all disciplines accountable for achieving outcomes. Daily practices that promote communication and review can reveal many opportunities for improved performance.5 IMPACT OF SELECT APPLICATIONS The goal of CM in all realms of practice remains the same, and it can have a positive impact on the economics of the health care system. Here are some real examples of programs that demonstrate the value of effective CM. Managed Care Plans HealthPartners is a nonprofit health organization based in Minnesota that TCM 56
July/August 2004
provides health services and insurance to more than 670,000 members. Participants are treated by the HealthPartners contracted medical groups or health care systems. When patients are asked about health goals, they don’t say they want their systolic blood pressure to be less than 130, for example. Instead, they tell their case manager they want to be healthy enough to travel to see the birth of their grandchild. For example, an older woman who was enrolled in this program told her case manager that she wanted to be able to clean her own home and shop for groceries. In order to do this she needed knee replacement surgery, but her weight, diabetes, and hypertension made the surgery risky. The case manager referred the client to HealthPartner’s diabetic education program. She called her client frequently and had biweekly meetings to reinforce the dietary and lifestyle changes. The client started exercising and got her blood pressure, blood sugar, and weight down so that she could have the surgery. Since HealthPartners began the CM program, the per-member per-month cost
A primary goal in disease management is to prevent long-term complications. Managed care organizations have used CM to control their costs associated with patients with chronic disease. A study was conducted to answer the question: Can case managers make a difference in diabetes management? This study was done at a New York medical CM firm. Adequate therapy for diabetes means normalizing the patient’s hemoglobin A1c lab value (HbA1c), monitoring treatment, and implementing prevention strategies to avoid complications. The case managers developed care plans for each patient and identified opportunities for improvement. After 2 years, 70% of those case-managed demonstrated improved HbA1c, indicating better control of their disease. The cost of improving glycemic control is substantial. Both patients and employers prefer preventive services to treatment of complications. Dialysis costs much more than a diabetic education program.7 Home Health Care Various home-based interventions have been used to improve the quality of the discharge process from the hospital. In Australia, a postacute care (PAC) program was developed that uses the theory of CM. A coordinator (case manager) plans for home care needs after hospital discharge. Services such as skilled nursing care, physical therapy, personal care, and meals are arranged for those who require them. A study was done to compare participants who have a PAC coordinator with usual discharge planning. The patients were 65 years and older and were followed for 6 months. The results suggest that this program improves overall health while decreasing costs to the
health care system. The PAC group had significantly greater improvements in independent living. The hospital bedday use was lower in the PAC group than in the control group, as were hospital utilization costs in the 6 months after discharge. This study provides evidence that CM as the coordination of home care services can be a profitable component of discharge planning.8 Another successful example of CM involves the Hartford Physician Hospital Organization. This group implemented a community-based CM program in June 1999 that was staffed by 3 registered nurses with extensive CM and home care experience. It promoted the suitable utilization of available services. Candidates for CM were patients who had more than one emergency room (ER) visit, more than one inpatient admission, or an inpatient stay longer than 10 days. The time frame was 1 year. The patient’s primary care physician was notified of the patient’s enrollment and asked to monitor the patient’s progress. Patients were assessed for physical issues and caregiver, social, and financial issues. The case managers worked to ensure that all available levels of support for the patient were explored. Community resources, such as programs offered by church groups, were used as needed. As a result of this community-based program, members rated their perception of health higher: 60.3% reported their health as good, compared with 24.7% before entering the program. The number of ER visits, hospital days, and inpatient admissions all decreased after the implementation. The frail, elderly patients known as “frequent fliers” were admitted less often and for shorter stays after enrolling in the program. The average savings per patient in the first year was $3963.94, which included ER visits, hospital admissions, and pharmaceuticals.9 The coordination of services and continued monitoring of outcomes is an essential component of home care CM. The use of technology has permeated all aspects of health care delivery. The last example of a successful home care program involved interactive home and telehealth at Pitt County Memorial Hos-
pital in North Carolina. The program focused on the high-risk patients of frail, elderly residents in assisted living facilities. Interactive home telehealth equipment was used by nurse case managers to conduct face-to-face visits with clients, assess heart and lung sounds, and obtain vital signs. The technology was received positively by the clients. Electronic medical records allowed easy contact with physicians, who could analyze data themselves without directly observing patients. If the data generated concern, a timely outpatient appointment was made. The program served more than 250 patients, and more than 90 complex clients were case managed.
They worked with all disciplines to ensure compliance with critical pathway guidelines, closely monitor length of stay and ancillary utilization, and identify opportunities for practice change. The results of the use of interactive telehealth included a 52% decrease in hospital admissions, a 45% decrease in total hospital days, and a 34% decrease in ER visits. These savings outweighed the cost of equipment. The incorporation of interactive home telehealth has decreased utilization of acute care services and demonstrated improved clinical outcomes.10 Hospital The nurse case manager in the acute care setting is an outgrowth of cost-containment practices. CM in the hospital setting is used to fill gaps in the delivery system as a cost-effective way to maintain quality care. Case in point— Allegheny General Hospital in Pennsylvania implemented CM for a targeted
population. A multidisciplinary team was assembled to discuss the geriatric patient with a hip fracture and to proactively address problems. Case managers were charged with developing a critical pathway for patients along with standard physician orders. Case managers ensured that the pathway was followed and monitored variances. Timely consults were obtained, and complications were analyzed. The Geriatric Orthopedic Hip Fracture Program saw various positive results.11 The accomplishments included a decrease in mortality rate (11%) compared with the national average (14%). The average length of stay went from 12.8 to 7.78 days. The number of patients who returned to home versus moving to skilled nursing facilities also increased. Another program revolved around patients undergoing cardiac surgery. To meet quality standards in the delivery of cost-effective hospital services, Johns Hopkins Hospital in Maryland initiated a CM pilot program. The case managers— clinical nurse specialists who worked collaboratively with nursing staff and residents—formed the link between the intensive care unit, step-down unit, and cardiac surgery floor. They worked with all disciplines to ensure compliance with critical pathway guidelines, closely monitor length of stay and ancillary utilization, and identify opportunities for practice change. Once these practice changes were identified, the case managers facilitated implementation. In short, the case managers provided continuity of the patient’s care from preadmission to discharge. The results speak for themselves. The average length of stay decreased from 13.3 to 11.7 days. The use of preadmission testing increased same-day admissions from 8 per month to an average of 31 per month. The monitoring of testing resulted in fewer arterial blood gases, laboratory studies, and radiology tests. The pilot program achieved $1.3 million in charge reductions. The role of the case manager has been to keep the patient moving toward discharge and to troubleshoot system issues as they occur. As a result of this pilot, future initiatives were identified, July/August 2004
TCM 57
such as the development of an early ventilator weaning protocol to enhance patient comfort and decrease cost. RECOMMENDATIONS FOR CASE MANAGEMENT To meet the ongoing challenges in our health care system, constant redesign and reevaluation of the delivery of patient care is required.12 As this article has shown, CM can be used to integrate health care delivery in a variety of settings. Emergency Rooms One potential implementation area is the ER. CM may be looked at in the ER as a revenue source in that it can help prevent an inpatient stay while maintaining the same level of care. Common avoidable ER admission diagnoses include pneumonia, congestive heart failure, cellulitis, and asthma.13 The ability to identify high-risk patients is crucial in the ER because costs are extremely steep for this care. It may be appropriate to treat cellulitis with intravenous antibiotics at home. A referral to a disease management program offered by a patient’s managed care plan may teach the patient to avoid asthma triggers and prevent an admission. Chronic Pain Management CM in managed care plans should focus on patients with chronic benign pain, who need a focused plan of care to manage their illness. Chronic pain can be defined as pain that lasts more than 6 months and beyond the time a person would expect it to stop.14 This population needs close monitoring of both inpatient and outpatient care. Patients need to be empowered to feel they can manage their pain and that pain does not manage them. Inpatient case managers need to facilitate prescription coverage to avoid admissions. Home health care managers need to monitor the effect the pain is having on a patient’s activities of daily living. Patients must understand how their pain is assessed and realize that they are a partner in their pain management. Education and follow-up are vital to the CM of these patients. Weight Management An alarming trend is emerging of adults and children who are obese or overTCM 58
July/August 2004
weight. An obese adult has a body mass index (BMI) of 30 or higher and faces an increased risk of premature death. In 2000, obesity cost $93 billion in annual medical bills,15 which makes this population an ideal target for CM. Referrals to diet education and exercise programs should be offered to those at high risk of developing chronic conditions associated with obesity. Drug therapy and surgery should be explored for those with diabetes, hypertension, and high cholesterol levels. Inpatient case managers should look at the “big picture” when an obese diabetic with chronic cellulitis is admitted. Dietary counseling and a discussion on weight management should be part of patient education. The federal government has begun a medical initiative to fight the obesity epidemic, and case managers can be proactive in this campaign. School Nursing The school nurse can be a starting point for problem identification and make appropriate referrals to get students on the right track. The overweight child who gets “sick” and repeatedly retreats to the nurse’s office during gym needs help. The child with attentiondeficit/hyperactivity disorder (ADHD) requires closer medical monitoring. Children with ADHD have more major injuries, more hospital admissions, and more ER visits than children without the disorder. One study found that the 9-year median medical costs for children with ADHD were $4306 compared with $1944 without it.16 Often, the school nurse is a bandage on a problem, but he or she could use CM for select students. Meetings with parents should be held to ensure medication compliance and physician monitoring. CONCLUSION CM has demonstrated success in the reduction of health care expenses. It will continue to evolve as a strong method to identify issues, obtain resources for patients, families, clinicians, and organizations, and evaluate the use of those resources. The case manager strives to balance the mission of quality care with the organization’s costs and the wellbeing of the patient. CM has and will
continue to have a positive economic impact on our health care system. ❑ References 1. Cohen E, Cesta T. Nursing case management: from concept to evaluation. St. Louis: Mosby-Year Book; 1993. 2. Calhoun J, Casey P. Redesigning case management in managed care. Lippincott’s Case Manage 2002;7:180-7. 3. More P, Mandell S. Nursing case management: an evolving practice. New York: McGraw-Hill; 1997. 4. Mullahy CM. The case manager’s handbook. 2nd ed. Gaithersburg (MD): Aspen Publishers; 1998. 5. Smith A. Case Management: key to access, quality and financial success. Nurs Economics 2003;21:237-44. 6. Patient-centered focus improves case management outcomes: members set personal goals rather than clinical milestones. Case Manage Advisor 2003;4:97-100. 7. Middleton J. The effect of case management on glycemic control in patients with type 2 diabetes. The Case Manager 2003;14:43-52. 8. Lim W, Lambert S, Gray L. Effectiveness of case management and postacute services in older people after hospital discharge. Med J Austral 2003;178:262-6. 9. Hanbury M, Seyler E, Upham S. Hartford Physicians Hospital organizations community case management program improves patient care while decreasing medical costs. Conn Med 2002;9:549-52. 10. Roupe MY. Interactive home telehealth: a vital component of disease management programs. Lippincott’s Case Manage 2004;9:47-9. 11. Leininger S. Protocols in practice: one year later did the quality circle of geriatric hip fracture care achieve quality outcomes? Lippincott’s Case Manage 1999;4:263-7. 12. Walrath J, Owens S, Dziwulski E. Case management—a vital link to performance improvement. Nurs Economics 1996;14 :117-24. 13. HealthCare Advisory Board. A delicate balance: managing the inpatient enterprise for profitable growth. Washington (DC): The Board; 2001. 14. Combine strategies to target chronic pain. Hosp Case Manage 2001;8:125. 15. Llewellyn A. Finding teachable moments: fighting the obesity epidemic. Continuing Care 2004;23:8-10. 16. ADHD kids cost more, sustain more injuries. Case Manage Advisor 2001;12: 65.
Ann Markle, BSN, RN-C, is a surgical case manager at Upstate Medical University in Syracuse, New York. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 188 doi:10.1016/j.casemgr.2004.06.003
C
Ann Markle, BSN, RN-C
ase management (CM) was initiated to manage resource utilization. With demonstrated success,
it was incorporated into acute care settings. As continued effectiveness was demonstrated, CM strategies were used in a variety of settings and with more populations and conditions. Today, it can be seen in a multitude of applications.
TCM 54
July/August 2004
This article demonstrates how CM can improve the health of our society and have a positive economic impact on our health care system. This strategy is instrumental in the coordination of fragmented services and the marshaling of health care resources. This article also describes evidence that supports the use of CM to control health care costs. OVERVIEW OF CURRENT APPLICATIONS Regardless of setting, a case manager looks at a variety of paths, solicits the most appropriate plan, and coordinates the support and expertise of other professionals, agencies, vendors, and family members. Managed Care Plans CM is not synonymous with managed care. The managed care system pairs a provider and patient and strives to man-
age costs, access, and quality of health care delivery. The Health Maintenance Organization Act, established in the early 1970s, started the growth of managed care programs. The health maintenance organization and preferred provider organization are both examples that seek to deter costly inpatient care through preventive and outpatient services. CM is used in these managed care plans as a cost-containment initiative.1 The general mission statement of a managed care organization is to provide quality health care for members while controlling costs. In this setting, case managers regulate access to specialists and services by necessitating medical justification for authorization. Patients with a high utilization of services, multiple chronic conditions, or a catastrophic illness may be targeted. The case manager then develops a plan of care and monitors the patient’s access to care, compliance, and results of the care provided. The case manager helps coordinate care for the client to achieve quality outcomes while demonstrating costeffectiveness.2 Home Health Care Most patients admitted to a hospital are discharged directly to home. With the aging of our society and the fact that people are living longer with chronic medical conditions, many people need home care services on either a temporary or permanent basis. The case manager plays a vital role in the coordination of these services. The acuity level of patients returning home has increased. Many treatments that were once provided only in hospitals can be done at home with proper support. The case manager works with the family, suppliers of durable medical equipment, and ancillary services, such as physical, occupational, and respiratory therapy. The case manager is responsible for ensuring complete home care staffing, visiting the patient as necessitated by the care plan, and serving as the contact person for problems. Problem identification in home care is a continual process, and resolution requires a collaborative effort among nursing and ancillary staff, physicians, family, and patient. The goal is to use allocated
resources in the most cost-effective way in a constantly changing environment.3 Rehabilitation Facility A rehabilitation facility treats cognitive and neuromuscular impairment and seeks to restore people with physical disability to their highest levels of functioning. The goal is to return the patient to an independent lifestyle. Many facilities today specialize in traumatic brain injuries, amputations, or spinal cord injuries.
Case managers regulate access to specialists and services by necessitating medical justification for authorization. The case manager in this setting must have specialized knowledge related to her client population. There is an interdisciplinary team dedicated to the care of the client. The case manager coordinates this team and ensures all necessary consults are obtained. Often the client is a young adult who is healthy but injured. Discharge planning is a major part of this CM role. The case manager is the liaison among team members and must collaborate with the insurance provider, equipment suppliers, home care managers, and physicians. The goal is for the patient to be assimilated back into society as a functioning member.3 Worker’s Compensation Worker’s compensation is another common CM setting. Regulations fall under the policy of the state in which they are written. These cases may be complex and involve collaboration with the claimant, employee insurance carrier, physician, and state worker’s compensation commission. The case manager coordinates all involved parties to achieve optimum health of the client
and timely return to the workforce. The case manager must possess extensive knowledge of regulations in all the states they serve.4 Hospital As discussed, the term CM means different things in different settings of the health care delivery system. The nurse case manager in a hospital manages access to care, coordinates its delivery, and strives for quality, cost-effective outcomes. CM is an approach and organizational attitude used to achieve those ends. A successful program requires administrative commitment, medical staff leadership, and physician accountability. Decreasing length of stay in the hospital is often the first assignment given to case managers. Patterns of prolonged length of stay can indicate complications or slow decision-making. Case managers must look at variances that increase length of stay and see what can be done to eliminate them.5 The first step in problem solving is to identify the problem. With the use of critical pathways, variances are analyzed to help identify the problem. The critical pathway describes special outcomes that must occur within a specified time frame. If the outcome is not completed by the projected time, a variance occurs.3 The CM department may be charged with the task of developing critical pathways in an effort to decrease length of stay. For example, the targeted length of stay for a patient undergoing a total knee replacement is 5 days. The case manager analyzes goals each day to see what was met or not met. She may find that there was no physical therapy service available on Sunday, so the patient did not receive it. Therapy was not done on postoperative day 4, and the patient felt too weak to go home on postoperative day 5 because he did not complete the expected course of therapy. The problem is identified. The case manager can bring this information to hospital administration and review options to eliminate this variance. Perhaps the scheduled operating day for the elective joint patients should be changed to accommodate a lack of weekend July/August 2004
TCM 55
dropped 24.7% and the hospitalization rate for those patients dropped 48%. The case managers screen patients and target populations who are at risk for major health problems. The clients picked for CM are not based on financial cost or disease but for their potential for acute care. The case managers help the members overcome any obstacles to obtaining care and achieving goals.6
Both patients and employers prefer preventive services to treatment of complications. scheduling. Another option may be to look at staffing for physical therapy for weekends. The cost of increasing the frequency of an ancillary service may be less than the addition of 1 hospital day to the length of stay. The case manager in the hospital setting revises every patient’s care every day. Interdisciplinary rounds are conducted to assess a patient’s response to treatment. The case manager organizes the team’s efforts to move a patient and family toward a desired goal. This team approach holds all disciplines accountable for achieving outcomes. Daily practices that promote communication and review can reveal many opportunities for improved performance.5 IMPACT OF SELECT APPLICATIONS The goal of CM in all realms of practice remains the same, and it can have a positive impact on the economics of the health care system. Here are some real examples of programs that demonstrate the value of effective CM. Managed Care Plans HealthPartners is a nonprofit health organization based in Minnesota that TCM 56
July/August 2004
provides health services and insurance to more than 670,000 members. Participants are treated by the HealthPartners contracted medical groups or health care systems. When patients are asked about health goals, they don’t say they want their systolic blood pressure to be less than 130, for example. Instead, they tell their case manager they want to be healthy enough to travel to see the birth of their grandchild. For example, an older woman who was enrolled in this program told her case manager that she wanted to be able to clean her own home and shop for groceries. In order to do this she needed knee replacement surgery, but her weight, diabetes, and hypertension made the surgery risky. The case manager referred the client to HealthPartner’s diabetic education program. She called her client frequently and had biweekly meetings to reinforce the dietary and lifestyle changes. The client started exercising and got her blood pressure, blood sugar, and weight down so that she could have the surgery. Since HealthPartners began the CM program, the per-member per-month cost
A primary goal in disease management is to prevent long-term complications. Managed care organizations have used CM to control their costs associated with patients with chronic disease. A study was conducted to answer the question: Can case managers make a difference in diabetes management? This study was done at a New York medical CM firm. Adequate therapy for diabetes means normalizing the patient’s hemoglobin A1c lab value (HbA1c), monitoring treatment, and implementing prevention strategies to avoid complications. The case managers developed care plans for each patient and identified opportunities for improvement. After 2 years, 70% of those case-managed demonstrated improved HbA1c, indicating better control of their disease. The cost of improving glycemic control is substantial. Both patients and employers prefer preventive services to treatment of complications. Dialysis costs much more than a diabetic education program.7 Home Health Care Various home-based interventions have been used to improve the quality of the discharge process from the hospital. In Australia, a postacute care (PAC) program was developed that uses the theory of CM. A coordinator (case manager) plans for home care needs after hospital discharge. Services such as skilled nursing care, physical therapy, personal care, and meals are arranged for those who require them. A study was done to compare participants who have a PAC coordinator with usual discharge planning. The patients were 65 years and older and were followed for 6 months. The results suggest that this program improves overall health while decreasing costs to the
health care system. The PAC group had significantly greater improvements in independent living. The hospital bedday use was lower in the PAC group than in the control group, as were hospital utilization costs in the 6 months after discharge. This study provides evidence that CM as the coordination of home care services can be a profitable component of discharge planning.8 Another successful example of CM involves the Hartford Physician Hospital Organization. This group implemented a community-based CM program in June 1999 that was staffed by 3 registered nurses with extensive CM and home care experience. It promoted the suitable utilization of available services. Candidates for CM were patients who had more than one emergency room (ER) visit, more than one inpatient admission, or an inpatient stay longer than 10 days. The time frame was 1 year. The patient’s primary care physician was notified of the patient’s enrollment and asked to monitor the patient’s progress. Patients were assessed for physical issues and caregiver, social, and financial issues. The case managers worked to ensure that all available levels of support for the patient were explored. Community resources, such as programs offered by church groups, were used as needed. As a result of this community-based program, members rated their perception of health higher: 60.3% reported their health as good, compared with 24.7% before entering the program. The number of ER visits, hospital days, and inpatient admissions all decreased after the implementation. The frail, elderly patients known as “frequent fliers” were admitted less often and for shorter stays after enrolling in the program. The average savings per patient in the first year was $3963.94, which included ER visits, hospital admissions, and pharmaceuticals.9 The coordination of services and continued monitoring of outcomes is an essential component of home care CM. The use of technology has permeated all aspects of health care delivery. The last example of a successful home care program involved interactive home and telehealth at Pitt County Memorial Hos-
pital in North Carolina. The program focused on the high-risk patients of frail, elderly residents in assisted living facilities. Interactive home telehealth equipment was used by nurse case managers to conduct face-to-face visits with clients, assess heart and lung sounds, and obtain vital signs. The technology was received positively by the clients. Electronic medical records allowed easy contact with physicians, who could analyze data themselves without directly observing patients. If the data generated concern, a timely outpatient appointment was made. The program served more than 250 patients, and more than 90 complex clients were case managed.
They worked with all disciplines to ensure compliance with critical pathway guidelines, closely monitor length of stay and ancillary utilization, and identify opportunities for practice change. The results of the use of interactive telehealth included a 52% decrease in hospital admissions, a 45% decrease in total hospital days, and a 34% decrease in ER visits. These savings outweighed the cost of equipment. The incorporation of interactive home telehealth has decreased utilization of acute care services and demonstrated improved clinical outcomes.10 Hospital The nurse case manager in the acute care setting is an outgrowth of cost-containment practices. CM in the hospital setting is used to fill gaps in the delivery system as a cost-effective way to maintain quality care. Case in point— Allegheny General Hospital in Pennsylvania implemented CM for a targeted
population. A multidisciplinary team was assembled to discuss the geriatric patient with a hip fracture and to proactively address problems. Case managers were charged with developing a critical pathway for patients along with standard physician orders. Case managers ensured that the pathway was followed and monitored variances. Timely consults were obtained, and complications were analyzed. The Geriatric Orthopedic Hip Fracture Program saw various positive results.11 The accomplishments included a decrease in mortality rate (11%) compared with the national average (14%). The average length of stay went from 12.8 to 7.78 days. The number of patients who returned to home versus moving to skilled nursing facilities also increased. Another program revolved around patients undergoing cardiac surgery. To meet quality standards in the delivery of cost-effective hospital services, Johns Hopkins Hospital in Maryland initiated a CM pilot program. The case managers— clinical nurse specialists who worked collaboratively with nursing staff and residents—formed the link between the intensive care unit, step-down unit, and cardiac surgery floor. They worked with all disciplines to ensure compliance with critical pathway guidelines, closely monitor length of stay and ancillary utilization, and identify opportunities for practice change. Once these practice changes were identified, the case managers facilitated implementation. In short, the case managers provided continuity of the patient’s care from preadmission to discharge. The results speak for themselves. The average length of stay decreased from 13.3 to 11.7 days. The use of preadmission testing increased same-day admissions from 8 per month to an average of 31 per month. The monitoring of testing resulted in fewer arterial blood gases, laboratory studies, and radiology tests. The pilot program achieved $1.3 million in charge reductions. The role of the case manager has been to keep the patient moving toward discharge and to troubleshoot system issues as they occur. As a result of this pilot, future initiatives were identified, July/August 2004
TCM 57
such as the development of an early ventilator weaning protocol to enhance patient comfort and decrease cost. RECOMMENDATIONS FOR CASE MANAGEMENT To meet the ongoing challenges in our health care system, constant redesign and reevaluation of the delivery of patient care is required.12 As this article has shown, CM can be used to integrate health care delivery in a variety of settings. Emergency Rooms One potential implementation area is the ER. CM may be looked at in the ER as a revenue source in that it can help prevent an inpatient stay while maintaining the same level of care. Common avoidable ER admission diagnoses include pneumonia, congestive heart failure, cellulitis, and asthma.13 The ability to identify high-risk patients is crucial in the ER because costs are extremely steep for this care. It may be appropriate to treat cellulitis with intravenous antibiotics at home. A referral to a disease management program offered by a patient’s managed care plan may teach the patient to avoid asthma triggers and prevent an admission. Chronic Pain Management CM in managed care plans should focus on patients with chronic benign pain, who need a focused plan of care to manage their illness. Chronic pain can be defined as pain that lasts more than 6 months and beyond the time a person would expect it to stop.14 This population needs close monitoring of both inpatient and outpatient care. Patients need to be empowered to feel they can manage their pain and that pain does not manage them. Inpatient case managers need to facilitate prescription coverage to avoid admissions. Home health care managers need to monitor the effect the pain is having on a patient’s activities of daily living. Patients must understand how their pain is assessed and realize that they are a partner in their pain management. Education and follow-up are vital to the CM of these patients. Weight Management An alarming trend is emerging of adults and children who are obese or overTCM 58
July/August 2004
weight. An obese adult has a body mass index (BMI) of 30 or higher and faces an increased risk of premature death. In 2000, obesity cost $93 billion in annual medical bills,15 which makes this population an ideal target for CM. Referrals to diet education and exercise programs should be offered to those at high risk of developing chronic conditions associated with obesity. Drug therapy and surgery should be explored for those with diabetes, hypertension, and high cholesterol levels. Inpatient case managers should look at the “big picture” when an obese diabetic with chronic cellulitis is admitted. Dietary counseling and a discussion on weight management should be part of patient education. The federal government has begun a medical initiative to fight the obesity epidemic, and case managers can be proactive in this campaign. School Nursing The school nurse can be a starting point for problem identification and make appropriate referrals to get students on the right track. The overweight child who gets “sick” and repeatedly retreats to the nurse’s office during gym needs help. The child with attentiondeficit/hyperactivity disorder (ADHD) requires closer medical monitoring. Children with ADHD have more major injuries, more hospital admissions, and more ER visits than children without the disorder. One study found that the 9-year median medical costs for children with ADHD were $4306 compared with $1944 without it.16 Often, the school nurse is a bandage on a problem, but he or she could use CM for select students. Meetings with parents should be held to ensure medication compliance and physician monitoring. CONCLUSION CM has demonstrated success in the reduction of health care expenses. It will continue to evolve as a strong method to identify issues, obtain resources for patients, families, clinicians, and organizations, and evaluate the use of those resources. The case manager strives to balance the mission of quality care with the organization’s costs and the wellbeing of the patient. CM has and will
continue to have a positive economic impact on our health care system. ❑ References 1. Cohen E, Cesta T. Nursing case management: from concept to evaluation. St. Louis: Mosby-Year Book; 1993. 2. Calhoun J, Casey P. Redesigning case management in managed care. Lippincott’s Case Manage 2002;7:180-7. 3. More P, Mandell S. Nursing case management: an evolving practice. New York: McGraw-Hill; 1997. 4. Mullahy CM. The case manager’s handbook. 2nd ed. Gaithersburg (MD): Aspen Publishers; 1998. 5. Smith A. Case Management: key to access, quality and financial success. Nurs Economics 2003;21:237-44. 6. Patient-centered focus improves case management outcomes: members set personal goals rather than clinical milestones. Case Manage Advisor 2003;4:97-100. 7. Middleton J. The effect of case management on glycemic control in patients with type 2 diabetes. The Case Manager 2003;14:43-52. 8. Lim W, Lambert S, Gray L. Effectiveness of case management and postacute services in older people after hospital discharge. Med J Austral 2003;178:262-6. 9. Hanbury M, Seyler E, Upham S. Hartford Physicians Hospital organizations community case management program improves patient care while decreasing medical costs. Conn Med 2002;9:549-52. 10. Roupe MY. Interactive home telehealth: a vital component of disease management programs. Lippincott’s Case Manage 2004;9:47-9. 11. Leininger S. Protocols in practice: one year later did the quality circle of geriatric hip fracture care achieve quality outcomes? Lippincott’s Case Manage 1999;4:263-7. 12. Walrath J, Owens S, Dziwulski E. Case management—a vital link to performance improvement. Nurs Economics 1996;14 :117-24. 13. HealthCare Advisory Board. A delicate balance: managing the inpatient enterprise for profitable growth. Washington (DC): The Board; 2001. 14. Combine strategies to target chronic pain. Hosp Case Manage 2001;8:125. 15. Llewellyn A. Finding teachable moments: fighting the obesity epidemic. Continuing Care 2004;23:8-10. 16. ADHD kids cost more, sustain more injuries. Case Manage Advisor 2001;12: 65.
Ann Markle, BSN, RN-C, is a surgical case manager at Upstate Medical University in Syracuse, New York. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 188 doi:10.1016/j.casemgr.2004.06.003