Chapter 28

Longitudinal care management: High risk care management

Chandra L. Torgerson and Lynda Hedstrom

Introduction

Although the United States spends more per capita on health care than any other country, 50% of Americans do not receive recommended preventive care, 30% do not receive needed care for acute medical conditions, and 40% go without necessary care for chronic conditions. As a group, Medicare beneficiaries have complex health care needs: 82% have at least one chronic condition; 20% have multiple chronic illnesses, accounting for two thirds of all Medicare spending; beneficiaries with multiple chronic illnesses account for 76% of all hospital admissions, and 70% of seniors do not receive recommended geriatric interventions (Centers for Disease Control and the Merck Company Foundation 2007).

Successful business models will depend on improving the ability to manage the risks of all segments of the population while improving quality (Bodenheimer 2003). Providers of Medicare Advantage Plans, such as United Healthcare Medicare & Retirement, have the infrastructure, interest and experience to coordinate care through targeted interventions and programs that are based on individual needs.

In the United Healthcare Medicare & Retirement High Risk Care Management Program, nursing (RN) care managers provide identified individuals with longitudinal telephonic case management. Longitudinal case management includes specific nursing interventions delivered over time while creating long-term relationships with members. Care managers work with the member to meet the member’s goals and perceived needs, address their symptoms and provide condition management. Interventions focus on long-term care planning, member education, coordination of services and a schedule of focused follow-up.

Data from this experimental study design, using multivariant testing, indicate a 25% reduction in hospital admissions for the targeted population. Participants are predominantly dually eligible Special Needs Plan members. The results suggest that a predictable set of clinical nursing interventions can be identified, tracked, studied, and tied directly to improved outcomes for individuals in care coordination programs.

Background

United Healthcare is committed to improving the lives of the more than 9 million Medicare members served through a variety of services and benefits offered through the health plans. United Healthcare has a rich history of clinical program deployment, including a focus on frail, at-risk populations. Evercare, United Healthcare’s flagship Special Needs Plan, was one of the first Centers for Medicare & Medicaid Services (CMS) demonstration projects for at-risk populations. This care model identifies frail elders living permanently in a nursing facility and provides a unique collection of services and benefits to the members residing there. In the Evercare model, assigned Nurse Practitioners provide ongoing services, including geriatric care, chronic condition management, appropriate prevention and wellness services, and advanced care planning. Nurse Practitioners have the ability to identify early changes in patient condition and bring care to the individual at the facility. This minimizes unnecessary transfers and hospitalizations, and improves quality of care resulting in greater member and family satisfaction (Kane et al. 2002; Kane et al. 2003; Kane et al. 2004).

In 2006, United Healthcare’s commitment to serving the frail and at-risk populations extended to those populations living in the community setting. The Dually Eligible Individual Special Needs Plans formalized a creative care coordination program to address the needs of this population. Outcomes of interest include ensuring access to care, improvement in quality, communication with the primary care physician, and reduction in cost.

Highlighting United Healthcare’s long-held value for the role of nursing in serving geriatric and frail populations, this clinical model was designed as a nurse-delivered telephonic care management model serving the frailest elders living in the community. The basic premise of the model is that nursing interventions can make a difference for dually eligible individuals, including those with multiple chronic conditions and a high need for community or caregiver support (Bodenheimer et al. 2002). These individuals could benefit from a long-term care management program using targeted interventions to address the needs of the individual comprehensively, rather than a short-term, face-to-face, or telephonic program. Identified individuals agree to participate and are assigned a care manager. They maintain continuous enrollment until they die or disenroll from the health plan. The target population includes individuals enrolled in United Healthcare’s Dual and Chronic Special Needs Plans with high CMS hierarchical condition category (HCC) scores (HCC scores of 4.27 or greater; Institute for Health Policy Solutions 2005). Referrals can be made into the program and individuals are then assessed for inclusion. A study was designed to determine what specific nursing interventions were effective in reducing unnecessary admissions to the hospital.

Rationale

Analysis conducted by the UnitedHealth Group Center for Health Reform and Modernization estimates that the United States will spend $5 trillion on health care for the dually eligible population over the next 10 years. This dually eligible population has many challenges. Demographics show that these individuals typically earn less than $20,000 per year, do not have a high school education, and many live in rural areas. These specific demographics lead to challenges in accessing and affording health care. Limited resources may also affect the individual’s ability to follow through with the needed care, unless extra support is offered. Nurse driven care coordination models can provide that support.

Intervention

The philosophical approach is to begin first “where the individual is” on enrollment into the program, where the individual’s basic needs and concerns are assessed and addressed (Lorig & Holman 2003). For example, it is unrealistic to consider disease management or self care if the individual doesn’t have enough to eat. Once basic needs and significant areas of concern are addressed, the care manager can begin to work with the member on chronic condition management and education. Helping the individual achieve a working relationship with their primary care provider is a valuable strategy. Individuals learn to plan their visits with their provider and learn how to talk with their physician about their concerns. Care managers will work directly with the primary care physician or nurse, if needed, to ensure the member’s needs are met. Management of care transitions and advanced care planning are priorities.

The following interventions have demonstrated a statistical difference in reducing hospital admissions. These are implemented and used in a standardized approach by all care managers with the members they serve.

Frequent touch

A decision-support tool based on certain criteria directs the nurse to the next touch point for an individual member. The criteria uses information gathered at each call to guide the process. The RN may call back the next day, in a week, or follow the standard protocol of 30 days.

Self management: change in condition

As individuals gain understanding of their chronic conditions and gain competency in managing their medications, an educational tool is introduced. This tool informs them of signs and symptoms that may indicate changes in their condition. The care manager works with the member and the tool to provide an action plan. The plan offers strategies in symptom management, such as dietary changes, taking prescribed medication, calling the physician or seeking care immediately in the emergency room. Care managers review this plan regularly with their assigned members.

Co-management with behavioral health specialists

Anxiety and depression have been shown to interfere with effective self-management of chronic conditions. This needs to be identified by the care manager and effective treatment initiated. When a care manager identifies an individual who may be demonstrating signs or symptoms of anxiety or depression, a consult with the individual’s primary physician is recommended. A behavioral health specialist is engaged if the member consents and co-management begins.

Advanced care planning using the five wishes document

During the assessment process individuals without advanced care directives are identified. The Five Wishes document is used to guide conversation with the individual. The care manager encourages the individual to discuss these wishes with their family and/or caregivers and make decisions if they so choose. Advanced Care Planning is an ongoing conversation which is included regularly in care management activities.

Care manager specific feedback on adherence to specified interventions

Individual care manager feedback is an important piece of ensuring that standard interventions are deployed for measurement. Activity reports inform the care manager regarding the outcomes they are responsible for, productivity standards and case loads. Care managers get information updated daily, weekly, and monthly regarding the individual, touches, member hospitalizations, and assessments/care plan completion. In addition, calls are recorded and reviewed with Supervisors to assess the quality of interactions and adherence to the priority interventions. Regular feedback on performance is shared with all care managers to improve their competency and professional development.

An unanticipated secondary impact: Staff performance

The whole process of identifying and testing effective nursing interventions in this structured way resulted in improved staff satisfaction and performance. This outcome had not been anticipated. Each intervention tested involved detailed recipes for implementation; with each member contact, care managers are required to follow a standardized process. Each care manager has to perform and document certain designated interventions in the same way. This degree of standardization allowed for consistency and thoroughness in documentation. It allowed consistent tracking of activities with data that could be trusted and acted upon. Care managers and supervisors alike can see what occurs between the member and their care manager. Productivity and application of the interventions are readily apparent.

In addition to standardization and consistency, the recipes allowed for better overall task management. Staff that had previously experienced difficulty in structuring their day became more efficient within a matter of days or weeks. Performance scores soared, increasing 30% or more on average. These performance measures are monitored weekly for each care manager and have not regressed over time.

One other development in the care manager team was a new appreciation for data or evidence to drive daily activities. Care managers were initially blinded from seeing which interventions were working until the results of the study were validated. The care managers couldn’t wait for the results. They became thoroughly engaged in the testing process and strived to obtain the best possible outcomes. They suggested new ideas for testing and process improvements and were eager to implement the results. This created an environment of continuous quality improvement and innovation within the team and a desire to practice based on what the evidence shows. This has also kept adherence to the proven interventions high – at 98% or greater. Staff retention remains greater than 90%.

Case studies

The cases and names have been altered and are not reflective of any single individual.

Case study #1

Dawn, the High Risk Case Manager, was assigned to Mary on June 2, 2009. The initial assessment and conversation included findings on several debilitating conditions.

Mary’s diabetes was being treated with daily Insulin of 60 units each morning, and she is to use sliding scale insulin based on her blood sugar levels throughout the day. A significant complication to her diabetes is the diagnosis of heart failure. Mary has been hospitalized repeatedly – four times in the last year. She is also morbidly obese and wheelchair bound.

Mary is dependent on others to bring her food; neighbors and a daughter stop by regularly. Unfortunately, the food they bring rarely adheres to her dietary requirements for diabetes and heart disease. From a practical perspective of managing in her home, Mary’s wheelchair would not fit through the bathroom door, forcing her to use a bedside commode. Mary was not able to get to her physician appointments, as local transportation could not accommodate her size and weight. The only medical treatment she received was in the local emergency room when she was transported by ambulance.

Dawn immediately identified several interventions to help Mary improve her health and quality of life. Dawn found a transportation provider who could accommodate Mary’s size and wheelchair, allowing her to get to and from her physician appointments. Mary is a very motivated individual and began to see her doctors and specialists on a regular basis. Dawn talked to Mary about basic needs and nutrition. By using Mary’s Medicaid benefits, she arranged for Mary to receive two meals a day delivered to her home that met her dietary requirements. Next, Dawn worked with the PCP office staff to find a personal care aide for assistance with ADLs. The aide was also able to help prepare meals in compliance with Mary’s dietary requirements. After lots of research by the care manager, a local charity arranged to have new doors put into Mary’s bathroom. A short series of visits from a home health physical therapist helped Mary to manage in the bathroom safely when she was alone.

During Dawn’s frequent follow up calls it became apparent that Mary was losing weight and feeling better. Over the course of a few months Mary was able to stop taking her daytime sliding scale insulin and reduced her morning insulin from 60 to 35 units. Her spirits began to lift and Dawn could tell a difference with every phone call.

After 18 months of care management, Mary’s progress was remarkable. Through support by Dawn’s prioritized and strategic case management interventions, Mary lost 185 pounds. She has a new wheelchair and no longer requires special bariatric transportation. She lost two shoe sizes and now has diabetic shoes. Her goal is to start walking again. She is compliant with her diet and doctor visits, and she is very proud of the steps she has taken to be healthier. Mary believes the nurse made the difference. Working together with Dawn through the comprehensive High Risk Care Management program gave her the resources and encouragement to begin living a healthier life.

Case study #2

Rosina, the High Risk Care Manager, has been working with Mark since January 2010. Mark is 71 years old with a history of colon cancer and a subsequent colostomy. Mark had been instructed in the hospital and was trying to manage alone but he just couldn’t get the colostomy bags to fit. At a scheduled monthly call, Rosina found that Mark’s sister, the primary caregiver, was frustrated because she could not get the necessary supplies for his colostomy. She had questions regarding the supplies that were needed and was unsure whether or not these supplies were covered under Mark’s insurance. Several calls to the insurance customer service line had left her with more questions than answers, and she had given up. She was also fearful of hurting Mark and she needed some basic instruction.

Rosina worked to find the right home health care provider to provide the necessary instructions, supplies, and support for Mark and his sister. Once Mark and his sister felt proficient, Rosina worked with the durable medical equipment company to regularly ship the needed supplies to their home. When Rosina called the primary care physician office to get the orders for the right supplies, the physician acknowledged the efforts of the care manager and appreciated the intervention in a very difficult situation. Mark is managing very well.

Rosina demonstrated that as a care manager she was a ready resource for them. Rosina continues with her regular contact and support for Mark and his caregiver.

Key learnings in high risk care management

Many lessons have been learned over the past three years in the High Risk Care Management program.

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