Embedded Case Management: A Hybrid Approach

A Hybrid Approach to Embedded Case Management

When a typical embedded and telephonic case management program didn't yield desired results, namely, coordination of quality care for their high-cost, high utilizers with complex, chronic diseases, Sentara Healthcare System took steps to correct it.

Step one was to re-evaluate the current program.

"When we really studied what they (RN Care managers) were doing, only about 25 percent of their time was spent doing care management. What happened was that they wound up becoming basically glorified office nurses. They were working on other projects from either the physicians or the practice manager," said Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group (SMG), which is part of Sentara Healthcare System, during A Hybrid Embedded Case Management Model: Sentara Medical Group's Approach, a recent 45-minute webinar sponsored by the Healthcare Intelligence Network.

In case you missed this webinar, you still have a chance to watch this highly-rated program.

Step two was to redefine the RN nurse care coordinators' job descriptions.

"We were focused on reducing the total cost of care...and improving patient satisfaction. We also measured quality of life. We were looking to see if engagement with an RN care manager improved the patient's perception of their quality of life," Morin says. To achieve this, SMG looked for RN care coordinators who could "engage patients for the long haul, know how to work with hospital-based caregivers, home health, and life care not just within their own healthcare system."

Core competencies were also established. "RN care managers are different than RNs. We were looking for people that didn't necessarily have previous care management experience, but who had experience doing patient assessments. They had to have a strong clinical background," Morin says.

Step three was to rebrand the model as a hybrid program.

The ideal was to establish and maintain patient-centered relationships, Morin continues. The RN care coordinators needed to conduct comprehensive initial assessments with the patient as well as ongoing assessments, so they could identify ongoing needs of the patients and possibly their caregiver, develop care plans and then provide coaching education. They also needed to provide support to both the patient and their caregivers and family members.

With this revamped program, SMG was able to achieve the following results through 2013:

Reduce ED visits by 17 percent;
Reduce all cause inpatient admissions by 48 percent;
Reduce all cause readmissions by 21 percent;
Improve seven-day follow-up rates by nearly double. Patients followed by a care manager had a 98 percent seven-day follow-up rate within the medical group; the average rate was 49.5;
Reduce total cost of care by 17 percent.

Psychological and functional health of patients was also improved, Morin says. Assessments pre-and post-engagement with care managers showed a 48 percent improvement in the first stages of depression, and a 6 percent improvement of physical health. And patient satisfaction also increased.

It all comes down to increased attention from the care manager, Morin says. One example is intense transition follow-ups, so that within 48 hours of discharge, the patient is seen or called, and given a clinical assessment. And prior to discharge? "We implemented a first call strategy. When the patient thinks of the emergency department (ED), we want them calling their care manager first."

You can "attend" this program right in your office and learn: the vision and goals of SMG care management; how patients are stratified for care management; the role of RN care managers at SMG; clinical outcomes and patient satisfaction achieved through the hybrid embedded model; and how care transitions are handled by the care managers.

It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.

You'll get to listen to the question and answer session to hear details on how to gain support for such a program through system leadership; case load; the role of the EMR in care management; the care management intake process; case management certification; protocols for patient inquiries about a potential emergency department visit; criteria for discharging a patient from the panel; and the role of home visits in Sentara's care management program.

To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of A Hybrid Embedded Case Management Model: Sentara Medical Group's Approach, please visit:
http://store.hin.com/product.asp?itemid=4923

I hope you find it useful.

Cordially,

Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network

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