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© 2012, Healthcare Intelligence Network — http://www.hin.com

New Horizons in Healthcare Case Management

Benchmarks, Metrics & Models

presented by the

Healthcare Intelligence Network

A publication of:The Healthcare Intelligence Network800 State Highway 71, Suite 2Sea Girt, NJ 08750Phone: (732) 449-4468Fax: (732) 449-4463http://www.hin.com

© 2012, Healthcare Intelligence Network — http://www.hin.com 2

Copyright ©2012 Healthcare Intelligence Network http://www.hin.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means — digital, electronic, mechanical, photocopying, recording or otherwise — or conveyed via the Internet or a Web site without prior written permission from the publisher.

Trademarks: AllScripts is a registered trademark of Allscripts Healthcare Solutions.Bluetooth is a registered trademark of Bluetooth SIG, Inc.Coumadin is a registered trademark of Bristol-Meyers Squibb Company.EPIC is a registered trademark of Epic Systems Corporation.Excel is a registered trademark of Microsoft Corporation.HEDIS is a registered trademark of the National Committee for Quality Assurance.Lasix is a registered trademark of Aventis Pharma, Inc.LOVENOX is a registered trademark of Sanofi-aventis U.S. LLC.Microsoft Access is a registered trademark of Microsoft Corporation.MyChart is a registered trademark of Epic Systems Corporation.ProvenHealth Navigator is a service mark of Geisinger Health System.PulseOx is a trademark of SPO Medical Equipment Ltd.Toprol is a registered trademark of AstraZeneca PLCTriple Aim is a trademark of Institute for Healthcare Improvement.

ISBN: 978-1-937229-53-5Manufactured in the United States of AmericaFebruary, 2012

New Horizons in Healthcare Case Management

Benchmarks, Metrics & ModelsI

This special report examines the latest trends in healthcare case management, with drawn from the most recent healthcare surveys administered by the Healthcare Intelligence Network.

Contributors:Toni Cesta, PhD, RN, FAAN, senior vice president of operational efficiency and capacity

management at Lutheran Medical Center in Brooklyn, New York

Connie T. Commander, RN-BC, BS, CCM, ABDA, CPUR, is the president of Commanderís Premier

Consulting Corporation

Michael Demagall, LNHA, LPN, administrator for Bath Manor & Windsong Care Center

Robert Fortini, PNP, vice president and chief clinical officer at Bon Secours Health System

Stuart Levine, MD, corporate medical director of HealthCare Partners Medical Group

Diane Littlewood, RN, BSN, CDE, regional manager of case management for health services at

Geisinger Health Plan

Dr. Edward Phillips, MD, director of outpatient medical services at Spaulding Rehabilitation

Hospital Network and assistant professor of the Department of Physical Medicine and

Rehabilitation at Harvard Medical School

Rebecca Ramsay, BSN, MPH, senior manager of care support and clinical programs at CareOregon

Craig Samitt, MD, MBA, president and CEO of Dean Health System

Lisa Sasko, MA, MBA, director of clinical transformation at CDPHP

Charlene Schlude, RN, CCM, director of case management at CDPHP

Joann Sciandra, RN, BSN, CCM, director, case management strategic planning for health services,

Geisinger Health Plan

Jessica Simo, health center administrator at Duke Family Medicine

Marcia Wade, MD, FCCP, MMM, senior medical director at Aetna Medicare

Barbara Wall, JD, founder and principal of CareSync Consulting (formerly Hagen Wall Consulting)

Executive EditorMelanie Matthews

HIN executive vice president and chief operating officer

Project EditorsPatricia Donovan

Jessica Papay

Cover DesignJane Salmon


Chapter 1:2011 Benchmarks in Healthcare Case ManagementResponsibilities, Results & ROI

201 healthcare organizations describe the placement, responsibilities and impact of

case managers on utilization, cost and compliance.

“[The single most important responsibility of a case manager] is to follow patients

through the continuum of hospital care through discharge.”

> Hospital

“[The most important factor of a successful case management program] is to have a

team-oriented collaborative focus on the care and management of the patient, with a

coordinated effort in involving family to assist and monitor care.”

> Health plan

“[The most important contribution of the case manager] is the facilitation of the appropriate transition of care that can provide the best outcome based on patient

values and goals.”

> Hospital

“Being a patient advocate is one main responsibility of a case manager.”

> Self-insured ERISA trust


Chapter 1: Table of Contents

About the Healthcare Intelligence Network ........................................................... 1-1

Executive Summary ............................................................................................... 1-1

2011 Survey Highlights ........................................................................................... 1-1

Key Findings .......................................................................................................... 1-2

Case Management Program Details ..................................................................... 1-2

Case Management Results and ROI ...................................................................... 1-2

Methodology ......................................................................................................... 1-3

Respondent Demographics .................................................................................... 1-3

Comparison of 2010 Data to 2011 Data ..................................................................1-4

Analysis of 2011 Responses ...................................................................................1-6

Overview of Survey ............................................................................................... 1-6

The Health Plan Perspective ..................................................................................1-7

The Hospital Perspective .......................................................................................1-7

Respondents in Their Own Words .........................................................................1-9

Key Case Manager Responsibility: Health Plans ................................................... 1-9

Key Case Manager Responsibility: Hospitals ........................................................ 1-9

Successful Interventions and Partnerships: Health Plans ....................................1-10

Successful Interventions and Partnerships: Hospitals ......................................... 1-11

Program Success Factors: Health Plans ............................................................... 1-12

Program Success Factors: Hospitals ..................................................................... 1-12

Key Contribution of the Case Manager: Health Plans ......................................... 1-13

Key Contribution of the Case Manager: Hospitals ...............................................1-14

Planned Program Expansions: Health Plans ........................................................ 1-15

Planned Program Expansions: Hospitals .............................................................. 1-15

Conclusion ........................................................................................................... 1-16

Responses to Questions .......................................................................................1-17

Part I: Overall Survey Responses ......................................................................... 1-17

1:01: Utilizing Case Managers ....................................................................... 1-17

1:02: Adding Case Managers in the Next 12 Months....................................1-18

1:03: Populations Targeted by Case Managers .............................................1-18

1:04: Case Manager Work Locations ............................................................1-19

1:05: Participant Referral Methods ..............................................................1-19

1:06: Average Monthly Case Load ............................................................... 1-20

1:07: Case Manager Duties .......................................................................... 1-20

1:08: Case Manager Communication Tools .................................................. 1-21

1:09: Case Manager Educational Background .............................................. 1-21

1:10: Evaluating Case Manager Performance .............................................. 1-22

1:11: Diagnosis Most Impacted by Case Management ................................. 1-22

1:12: Impact of Case Management .............................................................. 1-23


1:13: Case Management ROI ........................................................................ 1-23

Part II: Responses from Health Plans ............................................................... 1-24

1:14: Respondent Organization Type ........................................................... 1-24

1:15: Health Plans: Utilizing Case Managers ................................................ 1-24

1:16: Health Plans: Populations Targeted by Case Managers ...................... 1-25

1:17: Health Plans - Case Manager Work Locations ..................................... 1-25

1:18: Health Plans - Participant Referral Methods ....................................... 1-26

1:19: Health Plans - Average Monthly Case Load ......................................... 1-26

1:20: Health Plans - Case Manager Duties ...................................................1-27

1:21: Health Plans - Case Manager Communication Tools ............................1-27

1:22: Health Plans - Case Manager Educational Background ...................... 1-28

1:23: Health Plans - Evaluating Case Manager Performance ...................... 1-28

1:24: Health Plans - Diagnosis Most Impacted by Case Management ....... 1-29

1:25: Health Plans - Impact of Case Management ...................................... 1-29

Part III: Responses from Hospitals .................................................................... 1-30

1:26: Health Plans - Case Management ROI ................................................ 1-30

1:27: Hospitals - Utilizing Case Managers ................................................... 1-30

1:28: Hospitals - Populations Targeted by Case Managers ........................... 1-31

1:29: Hospitals - Case Manager Work Locations ......................................... 1-31

1:30: Hospitals - Participant Referral Methods ............................................ 1-32

1:31: Hospitals - Average Monthly Case Load .............................................. 1-32

1:32: Hospitals - Case Manager Duties ....................................................... 1-33

1:33: Hospitals - Case Manager Communication Tools ............................... 1-33

1:34: Hospitals - Case Manager Educational Background ........................... 1-34

1:35: Hospitals - Evaluating Case Manager Performance ............................ 1-34

1:36: Hospitals - Diagnosis Most Impacted by Case Management .............. 1-35

1:37: Hospitals - Impact of Case Management ............................................ 1-35

1:38: Hospitals - Case Management ROI ..................................................... 1-36

Glossary .............................................................................................................. 1-37

2011 Healthcare Case Management Benchmark Survey Tool ................................ 1-38

About the Contributor .........................................................................................1-42


© 2012, Healthcare Intelligence Network — http://www.hin.com 1-1

About the Healthcare Intelligence Network

The Healthcare Intelligence Network (HIN) is an electronic publishing company providing high-quality information on the business of healthcare. In one place, healthcare executives can receive exclusive, customized up-to-the-minute information in five key areas: the healthcare and managed care industry, hospital and health system management, health law and regulation, behavioral healthcare and long-term care.

Executive Summary

Targeted case management interventions across the health continuum are resulting in more efficient and appropriate care coordination and utilization of healthcare resources.

In its second annual Healthcare Case Management e-survey, conducted in January 2011, the Healthcare Intelligence Network captured the details of contemporary case management and the evolving responsibilities of today’s case manager. Responses provided by 201 healthcare organizations to 24 multiple choice and open-ended questions indicate that not only are more organizations utilizing case managers, but the practice of embedding case managers at the point of care has become de rigueur. For example, the number of case managers working in hospital admissions offices nearly doubled from 2010 to 2011.

Additionally, the contemporary case manager’s job description is much more likely to include home visits, crisis management and quality improvement responsibilities in 2011 than it did in 2010. New this year: metrics on case managers co-located at long-term care facilities (page 1-19) and case managers’ health coaching duties (page 1-20).

2011 Survey Highlights

k Most responding organizations (91 percent) use case managers, up from 84 percent in 2010.

k Care coordination and patient education continue to be the top case manager duties in 2011, closely followed by discharge planning. Health coaching by case managers — a new area explored by this year’s survey — was reported by 48 percent of respondents.

The average case manager

case load is 50-99, say 35

percent of respondents.

1-1


What is the preferred educational background of a case manager?

Which of the following is considered when evaluating a case manager’s performance?

1:22: Health Plans - Case Manager Educational Background

Source: HIN Case Management SurveyJanuary, 2011

1:23: Health Plans - Evaluating Case Manager Performance

Source: HIN Case Management SurveyJanuary, 2011

©2012

©2012



Overview: Case Management in 2011 ..................................................................... 2-1

2011 Survey Highlights ��2-2

Conclusion ��2-3

Metric 1: Patient Education and Outreach ............................................................. 2-4

15 Steps to Improve Patient Education and Outreach ��2-4

Metric 2: Medication Adherence .............................................................................2-12

Case Management Approach to Medication Adherence ��2-12

Metric 3: Obesity and Weight Management .........................................................2-14

The Future of Disease Management ��2-14

Metric 4: Managing Care Transitions Across Sites ............................................2-16

6 Approaches to Care Transition Barriers ��2-16

Metric 5: Home Visits ..................................................................................................2-19

Home Visit Pilot Reduces Unplanned Readmissions ��2-19

Metric 6: HRAs in Case Management .....................................................................2-22

Using HRAs to Identify Risk in the Elderly ��2-23

5 Domains of Patient Assessment for Case Selection ��2-24

Metric 7: Reducing Avoidable Emergency Room Visits ...................................2-26

Case Management Strategies for High-Utilization ED Patients ��2-26

Metric 8: Reducing Hospital Readmissions .........................................................2-29

A Multidisciplinary Approach to Reducing Rehospitalization Rates ��2-30

Metric 9: Patient-Centered Medical Homes .........................................................2-33

Embedding Case Managers in the Primary Care Practice ��2-33

Metric 10: Improving Patient Experience & Satisfaction ................................2-36

Patient Satisfaction and ED Case Management ��2-36

Patient Satisfaction a Reality of Healthcare ��2-37

Glossary ...........................................................................................................................2-39

For More Information .................................................................................................2-40

About the Contributors ...............................................................................................2-45


List of Figures

Figure 1: Case Manager Utilization ��2-2

Figure 2: Case Manager Work Locations ��2-2

Figure 3: Primary Patient Educator ��2-4

Figure 4: Primary Contacts for Medication Adherence ��2-12

Figure 5: Case Management in Disease Management ��2-14

Figure 6: Primary Coordinators of Care Transitions ��2-16

Figure 7: Transitional Care Statistics �� 2-17

Figure 8: Primary Conductors of Home Visits ��2-19

Figure 9: 4 Reasons to Conduct Home Visits��2-20

Figure 10: Reviewers of HRA Results �� 2-22

Figure 11: HRA Outputs ��2-23

Figure 12: Uses for HRA Data ��2-23

Figure 13: HRAs Linked to Care Management Program ��2-24

Figure 14: Staffing Models to Reduce Avoidable ER Use ��2-26

Figure 15: 5 Reasons to Embed a Case Manager in the ED �� 2-27

Figure 16: Strategies to Reduce Readmissions ��2-29

Figure 17: Primary Responsibility for Reducing Readmissions ��2-30

Figure 18: Stratifying Patients into Care Management ��2-31

Figure 19: Professionals on the PCMH Team ��2-33

Figure 20: Embedded Case Managers �� 2-34

Figure 21: Details of Embedded Case Management �� 2-34

Figure 22: Primary Responsibility for Improving Patient Satisfaction��2-36

Figure 23: Impact of Case Management on Patient Satisfaction ��2-37

Figure 24: Scorecard Example for Unblinded Patient Satisfaction ��2-38


that we have major impact in improving when we use the behavior modification piece�

Metric 3: Obesity and Weight Management

D espite early indicators of success on the obesity management front, this condition is still tied to an estimated $117 billion in healthcare costs�

Not included in this estimate are indirect costs of obesity — income lost from decreased productivity, restricted activity, absenteeism and bed days� Obese individuals in the U�S� are at greater risk for chronic disease — type 2 diabetes, cardiovascular disease, hypertension, stroke and even some forms of cancer�

Nearly 21 percent of respondents to the April 2010 survey on Obesity and Weight Management said that case management is an important aspect of obesity and weight management programs for children/adolescents� (See Figure 5�) (See “For More Information�”) The survey captured the steps organizations are taking to prevent and reduce obesity and related conditions and costs� Through responses provided by 131 healthcare organizations to 21 multiple choice and open-ended questions, the survey results reveal that nutrition counseling, weight management and exercise classes are the three most frequent components of organizational programs aimed at preventing or reducing obesity�

The Future of Disease Management

By Edward M. Phillips, MD, is assistant professor of physical medicine and rehabilitation at Harvard Medical School. He is director of outpatient

medical services of the Spaulding Rehabilitation Hospital Network in Boston.

When I speak about lifestyle medicine, we like to focus on the behavior — whether someone is inactive, overeating, smoking — not the result of diseases� We also talk about using coaching from the physicians and health coaches sitting side-by-side with us, in the same

Survey Snapshot:

Topic: Obesity and Weight Management

Date: April 2010

Respondents: 131

Key Metric:

� 20.6% say case management is part of obesity and weight management programs directed toward children/adolescents.

Figure 5: Case Management in Disease Management

Source: HIN Obesity and Weight Management Survey, April 2010©2012



Payoffs of Placing Geisinger Case Managers at Primary Care Sites ............................3-1

Medical Home Model: The ProvenHealth Navigator .................................................3-2

The Embedded Case Manager .............................................................................................3-5

Selecting a Case Manager ......................................................................................................3-7

Case Manager Skill Sets and Key Qualities ....................................................................3-8

Case Manager Training and Support ............................................................................. 3-10

Identifying Target Populations for Case Management ..........................................3-11

Post-Discharge Case Management ................................................................................. 3-15

Case Management in Home Health, SNFs and Care Transitions .......................3-17

Success from the Case Manager Effort .........................................................................3-19

Healthcare Case Management: Focus on Care Transitions and Continuity .........3-20

Survey Highlights ................................................................................................................... 3-21

Key Findings ............................................................................................................................. 3-21

About the Survey ....................................................................................................................3-23

Respondent Demographics................................................................................................ 3-23

Q&A: Ask the Experts ...................................................................................................................3-24

What is a Complex Case? ....................................................................................................3-24

Integrating the Medical Home with the Health Plan ..............................................3-24

Technology Supporting the Medical Home Model ..................................................3-25

Staffing the Case Manager Call Center ..........................................................................3-25

Home Health and Home Visits ......................................................................................... 3-25

Stratifying Complex Patients ............................................................................................ 3-26

Case Manager Competencies ............................................................................................ 3-26

Investment in Medical Home Infrastructure .............................................................3-27

Targeted Case Management Populations ....................................................................3-27

The Case Manager’s Role in the Practice .....................................................................3-27

Engaging the Practice in the Program .......................................................................... 3-28

Making the Most of the Case Manager Resource .....................................................3-28

Case-Managing the Sick of the Sickest ..........................................................................3-29

Building Physician Buy-In for the Embedded Case Manager .............................3-29

Case Management Tools .....................................................................................................3-29

Predictive Modeling for Risk Identification ...............................................................3-30

Funding and Reimbursement for the Embedded Case Manager ......................3-30

CCM Certification ................................................................................................................... 3-30

Timeline for Program Implementation ........................................................................3-31

Importance of Technology in Program Model ..........................................................3-31

Glossary .............................................................................................................................................. 3-32

For More Information ..................................................................................................................3-33

About the Contributors ...............................................................................................................3-36


The Medical Home Case Manager:

Profiting from Patient-Centered Care

In a new survey of healthcare organizations on the patient-centered medical home model, 60 percent of respondents include case managers on the medical home care team, with more than half of these respondents embedding these case managers within the primary care practice. An early adopter of this trend is Geisinger Health Plan. This special report provides an inside look at the selection, training, skill set, processes and benefits of Geisinger Health Plan’s embedded case managers who are working on site in the payor’s medical home practices.

Payoffs of Placing Geisinger Case Managers at Primary Care Sites

G eisinger Healthcare System is an integrated health service organization. We are linked with providers, facilities, physician practice groups and

managed care companies, which comprise the Geisinger Health Plan (GHP). We are in central Pennsylvania, and our main hospital is in Danville.

Figure 1 on page 3-2 illustrates our integrated service organization. We have over 40 community service practice sites with 700 physicians and our practice group also entertains 200 interns and a residency program as well.

The success of our patient-centered medical home (PCMH) model is from the relationship that we have with our physician practice group and the GHP. Our physician practice group brings to this model the physicians, the practice sites and the patient population. As a managed care company, we employ 70 case managers who are integral to the PCMH model. We also have a robust clinical reporting department and an actuarial department that bring success to the model. We’re fortunate to be in partnership with our physician practice group.

As a health plan, population profiling and segmentation are part of our service. We use predictive modeling in profiling and segmentation, and we have case management on site. We have a disease management (DM) department with traveling nurses and a remote monitoring system for heart failure (HF) and transitions of care.

Our focus is on embedded case managers — how we choose them and train them and some of the skill sets necessary and valuable in providing case

Diane Littlewood, RN, BSN, CDE, is a regional manager

of case management for health services for Geisinger

Health Plan, and Joann Sciandra, RN, BSN, CCM, is

director, case management strategic planning for

health services forGeisinger Health Plan..


Q&A: Ask the Experts

In this roundtable discussion, HIN’s expert panelists respond to queries based on topics presented in this report.

What is a Complex Case?

Question: What constitutes a complex case?

Response: (Diane Littlewood) We use different tools, such as the driving force of the case, the presence of HF, the complexity and acuity of the case and the hospitalizations involved. The chronicity that’s involved helps to identify that complex case.

Integrating the Medical Home with the Health Plan

Question: How do providers’ medical homes integrate with medical plan benefits and shared success between practice and plan? Some examples would include: scope of roles and responsibilities, integration of health plan data, integration with health plan care management programs and measurements that define success.

Response: (Joann Sciandra) The key to our success has been exactly what that question raises — the integration of GHP within the primary care sites. If that integration didn’t occur in the working relationship within our community practice sites, we would not be where we are today.

When we bring up a new site, we go out to the site and do an orientation. We educate everyone on medical homes and our goals. We have 10 quality metrics that the site agrees to; these metrics are reviewed throughout the year and will be measured at the end of the year. We make the whole site part of the medical home. Every individual in that site has an important role, and that’s been a key to our success. The person who answers the phone is as important as the provider. We have seen a chain of success by doing it that way. At our meetings, we share metrics, readmission rates, ER per member per month, generic versus brand and ambulatory care services. We consider whether we are doing enough at a site. Sometimes we’ll see some primary care sites that are low, and ask, “What do we need to do to get patients in more?” We’ll look at our colonoscopy rates. “Why are they low?” “Do we need to reach out?” Having the claims makes this relationship valid and facilitates change.



Bon Secours Embedded Nurse Navigators Transform Primary Care ........................4-1

Division of Labor in a Medical Home ...............................................................................4-3

Three Phases of the Advanced Medical Home .............................................................4-3

Care Team Formation ..............................................................................................................4-4

Efficient Use of Registries .....................................................................................................4-6

Identifying Case Loads and Levels of Patient Management ...................................4-7

Tools to Support the Embedded Case Managers .......................................................4-8

Measuring Success Metrics ...................................................................................................4-9

The Role of the Embedded Case Manager in Clinical Transformation ...................4-11

History of the Enhanced Primary Care Program .....................................................4-11

Steps to Practice Transformation and Payment Reform ......................................4-12

Analyzing Savings in a Pilot Practice ............................................................................ 4-13

Implementing Embedded Case Management ..................................................................4-15

Incorporating the Triple Aim Initiative ......................................................................4-16

Expanding Programs and Practices ...............................................................................4-16

5 Criteria for Selecting Practices ..................................................................................... 4-17

Impact of Practice Transformation ................................................................................ 4-18

Stratification and Prioritization ..................................................................................... 4-18

Primary Day-to-Day Nurse Roles and Responsibilities .........................................4-19

Reducing Gaps in Care .........................................................................................................4-20

Case load and Schedules of an Embedded Case Manager ...................................4-20

Collaboration with Pharmacies .......................................................................................4-22

High-Risk Populations and Dual Diagnosis Care .....................................................4-24

Identifying Desired Outcomes .......................................................................................... 4-24

Costs Associated with Embedded Case Managers ..................................................4-25

Outcomes and Lessons Learned ...................................................................................... 4-26

Q&A: Ask the Experts ...................................................................................................................4-27

Adding RN Case Managers .................................................................................................4-27

Training Process for Case Managers ............................................................................. 4-28

Case Manager Productivity Benchmarks.....................................................................4-28

Completing Pre-Huddle Reviews .................................................................................... 4-29

Licensing SARG ....................................................................................................................... 4-29

Case Manager Cost Savings ...............................................................................................4-29

Physician Incentive Model .................................................................................................4-30

Determining Patient Risk ...................................................................................................4-30

Case Management Certification ....................................................................................... 4-31

Further Case Management Training .............................................................................. 4-31

Relative Readmission Index .............................................................................................. 4-31

Utilizing Evidence-Based Teaching Tools ....................................................................4-32


Observation Stays .................................................................................................................. 4-32

Partnering with Health Plans ........................................................................................... 4-32

Incentives for Case Management Activities................................................................4-33

Utilizing the Model in Specialty Practices ...................................................................4-33

Hospital Affiliations and Influence.................................................................................4-33

Program Implementation and Demographics ...........................................................4-33

Allocation of Care Management ...................................................................................... 4-34

Case Manager Outreach ......................................................................................................4-34

Use of MyChart Patient Portal .......................................................................................... 4-34

Payment Models ..................................................................................................................... 4-34

Case Manager Background ................................................................................................4-35

Choosing Case Managers ....................................................................................................4-35

Embedded Case Manager Tools .......................................................................................4-35

IT Capabilities.......................................................................................................................... 4-36

Allocation of Staff ...................................................................................................................4-36

Locating Care Managers......................................................................................................4-37

Case Manager Communication Methods .....................................................................4-37

Identifying PMPM Cost ........................................................................................................4-37

Partnering Case Managers with Newly Diagnosed Patients ...............................4-38

Gauging Member Satisfaction and Service .................................................................4-38

Patient Cost for Case Management ................................................................................ 4-38

Affiliation of Embedded Nurses ......................................................................................4-39

Glossary .............................................................................................................................................. 4-41

For More Information ..................................................................................................................4-42

About the Contributors ...............................................................................................................4-45


Case Managers in the Primary Care Practice:

Tools, Assessments and Workflows for Embedded Care Coordination

This special report examines two parallel East Coast efforts in embedded case management: Nurse Navigators in Bon Secours Health System’s Advanced Medical Home program, and Nurse Case Managers at the heart of CDPHP’s Enhanced Primary Care effort.

Following in the footsteps of Geisinger Health System’s embedded case manager model, both initiatives are driven by the same core desire to move from a provider-centered to a patient-centered model. Both organizations say the model is helping to reduce hospital readmissions and ER visits and tighten transitions of care for high-risk patients.

Bon Secours Embedded Nurse Navigators Transform Primary Care

W e are going to talk about the Clinical Transformation project underway in the Bon Secours of Virginia Medical Group. We have

about 350 employed physicians at 80 locations across Virginia from Virginia Beach into the Richmond area. My team has been charged with transforming the way care is delivered.

Figure 1 shows something everyone should be familiar with these days — the concept of a medical home. It references the principles of a medical home as crafted by the American Academy of Family Practice (AAFP). It is the basis for a number of different recognition programs, first and foremost the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) Recognition program. (See “For More Information.”)

Robert Fortini is vice president and chief clinical

officer at Bon Secours Health System.

BSMG Medical Home Clinical Transformation Project

� The goal of a PCMH is to improve quality, efficiency and satisfaction for both patients and physicians. This is done by providing prompt, cost-effective, and coordinated access to a comprehensive range of services — to provide a “System of Care.”

� To maintain organizational “Alignment” with new revenue lines: “Meaningful Use,” PQRI, HEDIS, ACO.

� To improve “Capacity and Compliance.”

http://www.emmisolutions.com/medicalhome/pcpcc

Source: Robert Fortini, Bon Secours Health System

Figure 1

Locating Care Managers

Question: Has it been difficult to find the RN care managers?

Response: (Charlene Schlude) It hasn’t. We had a fairly large case management program to begin with. We chose to deploy seasoned case managers who are already working here at the health plan on our telephonic program first. Now we will be hiring additional case managers. Then we hope to continue to backfill and train for the telephonic program, always trying to take our more established nurses. It can be sometimes difficult because it’s not as if you can recruit someone with previous medical practice experience in a PCMH because it is fairly new, and there aren’t many people with that experience. I have a few nurses that previously worked in a practice and worked clinically in the health plan. That was helpful because they understood the culture of a practice. You don’t want to disrupt that workflow.

Case Manager Communication Methods

Question: Do the case managers use e-mail or text messaging to keep in touch with their members?

Response: (Charlene Schlude) We currently cannot e-mail our members. We are getting a new care management system in December. We will be able to e-mail. We have not been e-mailing from our current system due to confidentiality concerns, but the new system will have that capability. It will have a member portal and security built in it for that. As a health plan, we have an initiative to try and gain e-mails on our members so that we have more access to that. Text messaging is something that we are very interested in because we know that many people like to use text. The only texting we are doing is a program called Text4baby, which is for maternity cases. It is a program that we offer to people, and they just have to opt in to receive text-pushed messaging. That is the only texting technology we are using right now.

Identifying PMPM Cost

Question: Are you using any resources that help you identify where the biggest impact can be made on PMPM cost?

Response: (Charlene Schlude) That is the ROI methodology that we are looking to develop, and we are going to be working with a consultant to help us do that. In case management, if you talk nationally to people about ROI for case management, it is difficult to track or identify it because the interventions around case management are so broad and so varied from social to financial to education. It becomes challenging. We are looking for support and consulting to help us with that. It will probably be associated with a comparison of inpatient


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