Impact of Point-of-Care Case Management on Readmissions and Costs
Published Online: August 16, 2012
Andrew Kolbasovsky, PsyD, MBA; Joseph Zeitlin, MD; and William Gillespie, MD
The rapidly rising costs of healthcare have led to a need to transform the current system. One of the primary goals of the Health Care Reform Act of 2010 was to transform healthcare by reducing overall costs while enhancing quality.1,2 Similarly, the Institute for Healthcare Improvement developed the Triple Aim initiative to encourage organizational transformations aimed at improving the health of the population, enhancing the experience of care, and reducing the per capita cost of healthcare.3 The cost of inpatient utilization is commonly cited as the largest driver of healthcare expenses.4,5 Yet despite the high costs of admission, readmissions in the 30 days following discharge are common.4,6-8 Development of programs aimed at enhancing transitions from the hospital has the potential to reduce readmissions and corresponding healthcare costs.
Managed care organizations (MCOs) are ideally positioned to implement innovative programs aimed at enhancing services to health plan members at risk for hospital readmission. However, traditional programs have experienced challenges that have often limited their ability to affect members. Typically, managed care programs have used claims to identify hospitalized members over a given period of time, and then targeted these members to receive outbound, telephone-based services from clinical staff aimed at reducing future readmissions.9,10 The lag time associated with obtaining and analyzing claims usually prevents timely identification and intervention in the critical first 30 days following discharge. While some organizations use predictive modeling software to identify high-risk members, these models are typically impacted by claims lag, lack of information from nonadministrative sources, and limited discriminative ability.9,11
Another challenge has been enrolling members into the programs. Managed care organizations often lack correct contact information, especially for their members without stable housing, who may be at the highest risk for admission. In addition, members may be wary of discussing health-related issues on the telephone with strangers.9 As a result, enrollment rates below 30% are common.9,12 Even among programs with higher enrollment rates, the mean time to identify and enroll a member may range from 37 to 100 days.9,13 Some experts have also suggested that many managed care programs lack the intensity to impact hospital utilization and have difficulty engaging physicians.13-15
Promising models with the potential to reduce readmissions have been developed.16,17 These models typically involve several key components that are delivered to individuals around the time of hospital discharge. These key interventions include medication reconciliation, identifying red flags for readmission and development of an action plan, needs assessment and linkage to resources, and timely postdischarge aftercare with a primary care physician (PCP) or specialist.18 The challenge for MCOs has been to find transformative ways to deliver these services via an intervention that incorporates diverse clinical specialties, identifies members at or before the time of discharge, maintains a high enrollment rate, engages physicians, and has the intensity needed to reduce readmissions.
The purpose of this study was to measure the impact on 30-day readmission and associated costs of integrating a case management team consisting of a nurse, social worker, pharmacist, and 2 health navigators at the point of care in a medical group to deliver care transition and case management services to health plan members following a hospitalization.
This study used an intent-to-treat, historical control design. Point-of-care case management (POC) services were offered to plan members who were discharged from an acute inpatient hospitalization over a 3-month period. All members had commercial, Medicare, or Medicaid coverage with the same large northeastern MCO. Members were identified via hospital notification to the health plan during the preauthorization process. Members received outreach via telephone for the purpose of program enrollment. All eligible members— whether they were enrolled, unreachable, or declined program services—were included as part of the intervention group in all analyses. The baseline group consisted of all members identified via hospital notification during the preauthorization process over the corresponding 3-month period in the year prior to program initiation. The baseline group was identified using the exact same process and eligibility criteria used in the intervention group.
Eligibility for Inclusion
To be eligible for either the intervention group or the baseline group, a member must have been hospitalized for a nonpsychiatric, nonmaternity primary diagnosis and the hospitalization must have been reported to the health plan as part of the standard preauthorization process. In addition, the member must have been discharged home or left against medical advice. Members discharged to skilled nursing or other facilities were excluded.
A POC team consisting of a nurse case manager, social worker case manager, pharmacist, and 2 health navigators was integrated into a large urban medical group to work with hospitalized health plan members at 4 medical offices. These offices provide services to approximately 23,000 members under a capitated financial arrangement. These health plan members account for approximately 75% of the medical group’s patients; the remaining 25% are members of other health plans. Each of the offices provides both primary care and specialty services.
On a daily basis, hospitalized members were referred to a member of the POC team who, prior to discharge, attempted to contact the member via telephone for enrollment in the program. During the initial contact, the POC team member introduced the program and confirmed all contact information. In the weeks following initial contact, the team member discussed the importance of aftercare; ensured that a timely aftercare appointment was made; provided appointment reminders and rescheduled any missed aftercare appointments; performed a needs assessment and linked the member to health plan, medical group, and community resources; coached the member on communicating with the PCP; reviewed how to access care resources such as after-hours and express care; identified red flags for readmission; developed a plan of action; identified any barriers to treatment or medication adherence; and worked with the member to overcome these barriers. In addition, the POC team arranged for the pharmacist to conduct medication reconciliation. The pharmacist reviewed medication lists and had telephone or in-person meetings with members. In addition to their own caseload, each team member was also available to consult on cases whenever their specific specialty was needed. Health plan members were able to speak with the POC team via telephone or have face-toface meetings in the medical office. The team had access to members’ clinical information in the electronic medical records used by the medical group.
The baseline group consisted of members who met eligibility criteria during the corresponding 3-month time period 1 year prior to POC implementation. Members were patients at the same 4 medical offices and were identified using the same strategy and inclusion criteria that were used for the intervention group. Baseline group members had access to the same medical office services, with the exception of the POC program, which did not exist during the historical baseline time period.
The study measures included case management processes, inpatient utilization, and program costs.
Case Management Processes
Enrollment Rate. Enrollment rate refers to the percentage of members eligible for inclusion in the intervention group who were enrolled in the POC program. The goal was to enroll more than 75% of members.
Days to Enrollment. Days to enrollment was the average number of days between referral to the POC team and member enrollment. The goal was fewer than 7 days.
Days Managed. Days managed was the average number of days between the date a member was enrolled in the program and the date the case was closed. Inpatient Utilization
Readmissions. Readmissions were the number of readmissions at any hospital for a nonmaternity, non–mental health condition that were paid for by the plan as identified by claims in the 30 days following discharge.
Readmission Costs. Readmission costs were those paid by the plan for all readmissions at any hospital for a nonmaternity, non–mental health condition, as identified by claims, in the 30 days following discharge. Analysis was conducted with a 4-month lag to allow for the inclusion of late claims.
Annual Program Costs. Program costs included annual salaries paid to the nurse and social worker case managers, 2 health navigators, and a 2/5 full-time equivalent pharmacist for time spent providing services over the intervention period.
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