Empowering case managers to drive better patient outcomes

Effectively treating the sickest and neediest patients is one of the biggest challenges for hospitals and health systems.

These complex patients, who typically account for the highest utilizers of emergency department (ED) services, contribute to an estimated $38 billion in potentially unnecessary spending each year.

Yet even with the emergence of initiatives such as the Hospital Readmissions Reduction Program, which will lower reimbursement for a reported 2,573 underperforming hospitals for FY 2018, healthcare leaders have difficulty finding the right long-term solutions for the complex mix of patients who visit the ED most frequently. With a broad number of social determinants contributing to high utilization—from lifestyle factors (e.g., obesity, smoking, addiction), to financial and environmental issues (e.g., transient housing and limited public transportation)—it’s impossible to pinpoint one single solution that will satisfy everyone.

In addition to looking outward toward clinical specialists, behavioral programs and community resources that can help complex patients, hospitals should also look inward—and consider ways to support their patient case managers. These professionals, who are frequently overwhelmed with pulling together the right inpatient and outpatient resources for multiple high-risk individuals, are often underestimated in their potential to increase positive outcomes, reduce hospitalizations, and rein in costs.

Arming case managers with the right information at the right time, through the use of more sophisticated care coordination tools—beyond just an event notification system—can make an enormous difference clinically and financially.

Empowering case managers

Let’s imagine we could actually know everything about a high-utilizer of EDs—not just her smoking habit and history of heart disease, but also her exact environmental and social challenges.

Let’s say we can push a button and have instant access to those pertinent information about that patient, across the care continuum: contact information for her extended care team, insight into recent hospital visits, and patient-specific care guidelines written by those that know her best. If ED case managers had ready access to such information at the point of care—presented in a concise, easy-to-digest format—and then can add to that patient record—ED and post-discharge care will be optimized, making a hospital re-admission less likely.

And the ability for health systems to share data more easily is correlated with a higher rate of recovery among patients, as a 2012 case study of Medicaid patients who visited EDs in Washington State showed. When the EDs used technology that allowed healthcare professionals to exchange patient information in real-time, the number of high utilizers of ED services decreased significantly. By the end of the study, the State reported $34 million of savings in emergency costs, a 9.9 percent decline in ED visits and an associated reduction in opioid-related deaths thought due to a drop in opioid prescriptions.

Yet while technology is available to facilitate this level of success, it is largely untapped by healthcare leaders. Organizations tend to rely on internal data from their own, closed network when treating a patient, or at best allow access to their electronic medical record vendor’s limited network. Patients are then expected to relay critical information about their own care teams and medical histories, both slowing and ultimately undermining medical decision making.

The end result is that we so often lack valuable information at the point of care, information that could be critical for the patient, allowing us to avoid repeating tests or unnecessary admissions.

Coordinating care with the right information

By empowering care managers with the right kind of context, we strengthen their impact.

To illustrate this, let’s return to the scenario involving our fictional female patient, say, a 50-year-old diabetic woman who is newly admitted to the ED. The case manager receives an alert that this patient is overweight, relies on Medicaid, has multiple chronic conditions, and visited three EDs in the past month to treat frequent issues with her diabetes, along with symptoms of early heart failure. She has been assigned a primary care physician (PCP) through Medicaid but has never seen them; in addition, the case manager is alerted that this patient lives in an apartment across town with limited access to public transportation.

Because the comprehensive notification system has dispatched this information to the case manager as soon as the patient was admitted to the ED, the case manager can more quickly connect her to the most appropriate interventions.

Given this new insight into the patient’s particular medical issues, her frequent visits due to diabetes and heart failure, the case manager can now facilitate an appointment with her primary care physician and specialists to target those conditions. And knowing where the patient lives may streamline access to a community support group. Finally, noting the patient’s ongoing transportation limitations, the case manager can connect her with transportation resources (such as Access-A-Ride). Once the patient is discharged, these new care connections—ambulatory and community support specific to the patient’s needs—will reduce her need for future ED visits.

As this scenario demonstrates, hospital and health system leaders can halt the pattern of ED over-utilization by giving case managers technology that offers a bird’s eye view of high utilizers. Equipping case managers with the right tools drives better patient outcomes for, hospitals and the entire U.S. health system. As the US healthcare system moves even more toward a value-based care model, all of these benefits will only become more important in the years to come.

Ben Zaniello, MD, MPH, is a practicing physician and the chief medical officer at Collective Medical. Collective Medical has built the nation’s largest network for care collaboration.

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