Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients

Problem Addressed

• Lack of medical/social care integration in chronic care management programs: Although disease management programs exist for many chronic illnesses, most have a predominantly medical or social focus, with little integration across these areas.¹
• Poor transitional care: Patients undergoing transitions often face deficiencies in the quality of care, including insufficient education about self-management of their condition, conflicting advice regarding care, and a lack of an identified provider who can monitor their case during the transition.²
• Poorer outcomes, higher costs: Deficiencies in transitional care lead to higher costs, medical errors, and poor compliance with medications.^3,4

Description of the Innovative Activity

• Screening for eligible patients: The program identified older adult patients who were high-utilizers of Summa Health System emergency department (ED) and/or hospital services. Using a simple screening form (the Risk Appraisal Tool) nurses screened patients over the telephone or in person at the hospital or skilled nursing facility to determine whether care management services could improve quality of care and decrease costs.  
• Initial contact: Once patients were deemed to be potentially eligible for program participation, they were contacted by one of the program's advanced practice nurses; the nurse explained the program and asked if they could visit the patients to do an assessment.
• Assessment for program participation: Advanced practice nurses visited the patients at home, in the hospital, or in the skilled nursing facility to perform the assessment. The nurses used a Risk Appraisal Tool that assessed the following patient characteristics: confusion/cognitive impairment, difficulty with ambulating/self-care, fall(s) occurring within the past 2 months, lives alone/lacks caregiver, ED/hospital visit(s) within the past 60 days, taking five or more medications, or nurse/social worker recommendation. Typical program participant characteristics were as follows:
  • 65 years of age or older (97 percent of participants)
  • Common medical diagnoses: chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, cerebrovascular accident, hypertension, diabetes, osteoarthritis, and osteoporosis. An analysis of enrollees showed that 10 percent of enrollees had previously suffered a stroke.
  • Impaired activities of daily living or impaired instrumental activities of daily living. Analysis shows that most participants had activities of daily living deficits, including 40 percent with deficits related to bathing and ambulation and 25 percent with deficits related to dressing.
  • Overall, 92 percent of patients had at least one medical or social issue that required an intervention. For example, more than one-half of patients took between 5 and 10 prescriptions, while 37 percent took more than 10 prescriptions. Approximately 40 percent of patients lived alone, 26 percent had memory impairment, 55 percent tested positive on a depression screen, 47 percent had experienced one or more falls, 43 percent had incontinence, 41 percent had sleep disturbance, 25 percent had nutrition problems, and 13 percent had skin problems.  
• Interdisciplinary care plan development: After the initial assessment, an interdisciplinary team meeting was convened to review the patient's circumstances and develop a care plan. The core members include the geriatrician, the advanced practice nurse, a registered nurse (RN) care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed, including medical consultants in various specialties (e.g., pulmonology, cardiology, psychiatry, physical/occupational therapy). The team developed a care plan identifying problems and recommendations.
• Care plan implementation: The RN care manager assumed responsibility for implementing the patient's care plan. Care managers were assigned to specific primary care practices so that they could build relationships with practice physicians and staff members, easily and efficiently discuss patients, and ensure that recommendations were implemented swiftly.
• Primary care physician (PCP) involvement: The RN care manager met with the patient's PCP to review the recommendations, obtain input from the PCP, and ensure that no care plan elements were contraindicated. PCPs were paid a one-time fee for a plan-of-care meeting, based on a typical 15- to 20-minute office visit. PCPs and RN care managers interacted as needed on an ongoing basis to review and modify care plan.
• Ongoing contact with patient: The care plan was sent to the patient along with instructions on self-management. A triage schedule based on patient acuity delineated the number and types of contact the RN care manager initiated with the patient. Home visits were made as needed. 
• Participation in physician office visits: RN care managers attended PCP office visits with the patients, acted as "health translators" during visits with subspecialists, and ensured thorough and accurate transfer of information among caregivers.
• Patient education: The RN care managers provided patient education about their conditions, including self-care skills. Some examples of education given include avoiding "triggers" that can cause exacerbations, diet plans, physical activity suggestions, compliance with medications, and recommended follow up care and patient-physician communication. This education occurred in any of several settings, including over the phone, in the PCP office, and/or during home visits.
• Monitoring: The RN care manager assessed patient compliance with the care plan; alerted the PCP and the advanced practice nurse to significant changes in the patient's condition; communicated with the PCP regarding the patient's progress vis-a-vis desired outcomes; collaborated with other providers, including home care, acute care, nursing facility, and community agencies; and solicited assistance from the geriatrician when needed. 
• Collaboration with community agency case managers: Collaboration was informal; for example, if the patient was involved with Ohio's Pre-Admission Screening System Providing Options and Resources Today (PASSPORT) Medicaid waiver program, the advanced practice nurse would alert the PASSPORT care manager of the patient's participation in the care program. 

References/Related Articles

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Results

• Reported health improvements: About 70 percent of patients believe the program improved their health, made it easier for them to get health care services, and provided them with a better understanding of their disease. No participant reported a decline in health status over the 1-year program period. 
• Decreased costs: Hospital admissions per 1,000 participants dropped by between 10 and 20 percent, yielding estimated cost savings of roughly $600 to $1,000 per participant per month. However, because of "regression to the mean," the true cost savings is difficult to determine. Thus, innovators wanted to attempt a randomized, controlled trial to evaluate the impact of the model on quality of care and cost-effectiveness.
• High satisfaction: Ninety-two percent of participants said they would recommend the program, and 93 percent rated their experience in the program as good or excellent. In a physician satisfaction survey asking whether the program facilitated the ability to care for complex senior patients, 81 percent responded "most definitely," "yes," or "somewhat," whereas 17 percent were unsure.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Enlisting clinician support: The geriatrician head of the program talked to department chairpersons and attended department and family medicine and internal medicine resident meetings to give a 5-minute presentation about the Frail Elder Care Management Program and how it would work, highlight the one-time payment, and present data on successes with the Acute Care for Elders model. 
• Hiring and training care managers: Care managers were hired and trained regarding details of the care model.
  • Hiring: Each care manager was interviewed and assessed first for interpersonal skills, because they are important in establishing trust and a therapeutic relationship with patients; second for their experience with older adults; and third for their ability to effectively interface with PCPs.
  • Training: Each care manager was paired with an advanced practice nurse certified in geriatrics. Learning was case based. The care managers went with the advanced practice nurse on home visits and were provided with education regarding common geriatric syndromes, functional assessment, and medications. Ongoing learning occurred during weekly interdisciplinary care meetings during which new patients as well as review patients were presented to the team.
• Partnership with Area Agency on Aging: Over the past 10 years, the Summa Health System geriatrics department has been cultivating its relationship with the Area Agency on Aging, which is the manager of the Ohio Medicaid Waiver community-based long-term care program (PASSPORT). The agency executive director worked with Summa's lead geriatrician to promote the integration of the biomedical and psychosocial model of care. The goal was to foster collaboration between PASSPORT and Frail Elder Care Management Program care managers and ensure that all resources are coordinated. By incorporating coordination with community agencies, the Frail Elder Care Management Program helped tighten this relationship. 
• Initial pilot test: The geriatrics department developed the program and tested it during a pilot trial of 1,272 patients over 3 years. Based on successful results from the trial, the program obtained grant funding from the AHRQ to test the program in an RCT.

Resources Used and Skills Needed

• Staffing levels: The program implementation incorporated a caseload of 50 to 60 patients per care manager and 120 to 150 patients per social worker. However, depending on patient acuity and functionality, caseload may vary. As part of the RCT, advanced practice nurses and RN care managers are keeping a "manpower" log that tracks the time involved in 13 different groupings of tasks to better inform staffing levels.
• Required staff skills: Advanced practice nurses generally have a Master of Science Degree in Nursing; certification as a Clinical Nurse Specialist or Nurse Practitioner in Gerontology through the American Nurses Credentialing Center; at least 2 to 3 years experience in geriatrics in an outpatient setting, with at least 1 year involving some form of care management; a working knowledge of community resources; a very outgoing personality (which is critical to establishing relationships with patients and PCPs); an ability to work collaboratively on an interdisciplinary team; and an ability to lead and motivate others in a team. RN case managers generally have a Bachelor of Science Degree in Nursing; geriatrics certification or care management certification (this is desired but not required); at least 2 to 3 years experience in geriatrics in an outpatient or home care setting, with at least 1 year involved in some form of care management; a working knowledge of community resources; and an outgoing personality and good communication skills.
• Costs: The primary costs involve salaries and benefits for the advanced practice nurses and RN case managers; overall program costs are not available. 

Funding Sources

Agency for Healthcare Research and Quality; Summa Health System

• The program was funded internally by SummaCare Health Plan.
• The RCT was funded by AHRQ grant #1R01HSO14539-01A1. They are currently on a no-cost extension from AHRQ. Their foundation continues to support the project.

Getting Started with This Innovation

• Provide vision for why care coordination is important for patients, caregivers, and providers.
• Link concept to the institution's mission and values.
• Develop a strong business plan and secure a commitment of resources sufficient to get the program started when the return on investment may not be apparent.  
• Make a concerted effort to explain the program to PCPs and to win their support; emphasize how Medicare reimbursement can compensate these physicians for their time, at least minimally, to convey that their input is valued.  
• Expect case management to be very intensive during the first 3 months of the program, as patients are educated about their disease and how to communicate effectively with physicians.

Sustaining This Innovation

• Involve the PCP in the ongoing development and refinement of the care plan, both to improve the plan and prevent the PCP from feeling "forced" to implement the recommendations.
• Coordinate with other care managers from community agencies (e.g., PASSPORT) who may be involved with these patients, which helps to ensure seamless care.

Additional Considerations and Lessons

• Summa Health was able to work on another RCT aimed at improving advanced chronic illness planning with the patient and PCP due to the first project's success. This randomized controlled trial will enroll community-based long-term care waiver subjects after initial admission and enrollment into the PASSPORT program (Ohio’s community-based long-term care waiver program), called the PEACE trial (Promoting Effective Advance Care for Elders). Summa Health received a small pre-pilot grant from Summa Health System Foundation and have submitted for an RCT pilot from the National Palliative Care Research Center. Summa Health is also doing this project through partnership and collaboration with the local Area Agency on Aging.