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March 5, 2002

# case management

CAP grantees participated in a Technical Assistance call on March 5,
2002 that featured leaders from six different communities offering their
experience with case management procedures. Each of the speakers had
unique stories to share with the group.

SKYCAP (Southeast Kentucky Community Access Program)

Fran Feltner, director of the SKYCAP program and employee of the
University of Kentucky Center for Rural Health (UKCRH), spoke to
grantees about the case management program at SKYCAP, and offered her
advice for others attempting to provide similar services. SKYCAP employs
lay health workers known as Family Health Navigators (FHNs) to conduct
case and disease management activities. Case management and disease
management are combined into one model, focusing specifically on five
primary diseases: asthma, diabetes, heart disease, mental illness, and
hypertension.

FHNs are required to have a high school diploma, are trained by SKYCAP
prior to employment, and are supervised by an RN, LPN team leader,
physicians, and other providers in the community. They provide total
holistic health care services to their clients. They monitor clients'
immediate health concerns as well as their educational, social, and
emotional needs. FHNs perform the following specific services:

-   They conduct comprehensive home visits that include assessments of
    the client's and the family's needs for physical health, mental
    health and social services. They then provide information and
    education about available services, and how to access providers.

-   They act as a liaison between clients and their families, and
    service providers, and report anything that may impede clients from
    obtaining available services.

-   They work with multi-disciplinary teams to establish action plans
    for clients and families and ensure that the plans are carried out.

-   They link clients with related services and support groups, and
    provide emotional and educational support for clients and their
    families when appropriate.

FHNs serve as the primary health care contact for patients in need,
helping to keep them focused when they're visiting multiple providers or
specialists. The FHN is the one person a client can turn to at any time
for any health care or social needs.

SKYCAP's case management program relies on its customized management
information system (MIS). The system tracks clients in real time and
provides a comprehensive medical records database. Case managers and
physicians use the system to track client health status and activities.
Fifty community-based facilities refer to the program as well as provide
services. Eleven sites are directly connected to the system. Use of the
system has significantly reduced duplication of services and unnecessary
emergency department and hospital visits.

Ms. Feltner had the following recommendations for communities in the
process of establishing case management programs:

-   Assess what your organization defines as case management. What is
    your definition of case management vs. disease management? Will you
    combine the two?

-   Determine the key players on your case management team early on.
    Will they be physicians, social workers, or both? Identify your
    providers and determine who will act as case managers.

-   Identify your target population. If you have 6,000 individuals, how
    will you prioritize? Decide on your target population and any
    diseases you will focus on before you get started. Establish
    standard parameters and benchmarks.

-   Empower your clients to self-manage. Encourage them to be active
    participants in their own health care. Ask what kinds of services
    they need, and what kind of educational materials they're interested
    in.

-   Track your patients attentively. Are they taking the right
    medications? Are they attending their scheduled appointments?

-   Get family support for the patient whenever possible.

-   Conduct peer reviews to ensure that patients are receiving the care
    they need.

-   Consider developing a comprehensive MIS that will help case managers
    and providers communicate and track patients' care and progress.

Jackson Medical Mall Foundation/Hinds County Health Alliance (HCHA)

Fleetwood Loustalot, CFNP, Director of Case Management for the Hinds
County Health Alliance (HCHA), spoke to grantees about the current
program offered through the HCHA and the Jackson Medical Mall
Foundation. Jackson Medical Mall is a former shopping mall that has been
converted into converted into a facility with multiple medical clinics,
research programs, local university program extensions, and retail
stores. HCHA serves the community at Mall facilities and other clinics
located throughout the community.

HCHA distributes authorization forms and educational materials for its
services to the four major hospital systems in Jackson, Mississippi.
Caseworkers (Case Managers, Social Workers, etc.) at each hospital
determine which patients need HCHA services. Patients complete the
appropriate forms and then Caseworkers make referrals based on prior
participation with a PCP or general location of residency. The
Caseworkers send the referrals to HCHA clinics and schedule initial
follow-up appointments. Caseworkers at the hospitals also send the
authorization forms to HCHA for enrollment into the HCHA database. HCHA
case managers then contact patients to establish relationships and
determine need for further services such as transportation, eligibility
determination follow-up, medication assistance, case management/disease
management participation, or other services.

Patients are offered three primary services through HCHA's case
management program:

1.  *Public Program Enrollment*: Case managers conduct eligibility
    screenings to determine if patients are eligible for public programs
    such as CHIP, Medicaid, Medicare, etc.

2.  *Transportation Program*: HCHA hired a dispatcher and established a
    phone number for patients to call to receive public transportation
    information. The dispatcher reviews all available methods of public
    transport and refers the patient to the best choice.

3.  *Medication Program*: HCHA has several pharmacies located within its
    clinics in various locations. A tiered approach is used for each
    patient:

    -   *First option*: Obtain medications free of charge through local
        pharmaceutical company programs.

    -   *Second option*: Obtain discounted medications via the 340B Drug
        Program.

    -   *Third option*: Obtain discounted medications via manufacturers'
        Pharmaceutical Assistance Programs (PAPs). HCHA has been
        successful using the RxAssist program for PAPs, and is currently
        in the process of switching to MedData. Mr. Loustalot believed
        both programs are very helpful.

In addition to these programs, HCHA also offers two additional
innovative projects as part of its case management system:

1.  *Cellular phone distribution*: HCHA has established a relationship
    with a local telecommunications firm to obtain cellular phones at a
    significantly discounted rate. Cell phones are pre-programmed to
    make outgoing calls only to specified locations such as the
    pharmacy, clinic, transportation services, or case manager. Users
    can receive unlimited incoming calls free of charge. This service
    provides an essential communication link for patients who lack
    telephone access. Phones are only distributed to high-risk clients.

2.  *State-of-the-Art Kiosks:* HCHA has placed medical kiosks in
    multiple locations in Jackson Medical Mall and in service areas
    (such as grocery stores) located in outlying rural areas. Kiosks are
    used to monitor and record patient blood pressure, pulse, and
    weight, and send this information via the Internet to an online
    database used by physicians. The kiosks will eventually send this
    information directly to respective provider offices.

Mr. Loustalot explained one of the keys to the success of HCHA's case
management program is its relationship with the local hospital systems
and clinics. All four major hospital systems refer all of their
uninsured patients to HCHA for care.

HealthAssist of Greenville, North Carolina

Michelle Sawyer, Administrator for Regional Health Plans at University
Health Systems of Eastern Carolina, joined the call to discuss the
details of her collaborative's case management program. HealthAssist is
an expansion of an existing Medicaid Managed Care Program. The goal of
HealthAssist is to help increase the enrollment of patients into the
Medicaid program as well as to expand services available to uninsured
individuals who do not qualify for Medicaid or Medicare.

HealthAssist has four major components:

1.  Medical care offered through a network of primary care physicians,
    specialists, health departments, hospitals, and other providers.

2.  A medication assistance program that acquires discounted medications
    through manufacturer PAPs, private funds, and a strict formulary
    process.

3.  Community Resource Centers established throughout the community that
    offer health education, screenings, case management, and a limited
    amount of clinical care.

4.  Community-based case management services with a focus on disease
    management and service coordination.

HealthAssist's case managers are either nurses or social workers who
maintain offices directly within the communities they serve. The case
managers obtain patient information from participating primary care
providers who have adopted HealthAssist's standard of care guidelines.

HealthAssist employs risk stratification procedures to determine which
of their enrollees is in highest need for case management services.
Disease condition, utilization of hospital and emergency department
services, and disease management options are reviewed in the process of
choosing patients who qualify for HealthAssist's services. Like other
collaboratives, HealthAssist has merged its disease management and case
management programs. The program's focus has been on patients with
diabetes and asthma, but patients with cardiac conditions such as heart
failure will begin to be added to the case management program this year.

A noticeable reduction in emergency department visits occurred following
implementation of case management for Medicaid enrollees. The most
remarkable differences were seen among patients with asthma and
ambulatory care sensitive diseases (ACSDs). The expansion of this care
management model to the uninsured is a primary focus of HealthAssist.

Broward County

Sharon Zucci, RN, Manager from the Memorial Healthcare System (MHS) in
Broward County, Florida, spoke to grantees about Broward County's
combined disease/case management program. Before receiving their CAP
grant, MHS focused solely on case management. Additional support from
CAP funding has enabled the collaborative to add comprehensive disease
management to its existing program.

MHS defines its disease management program as "an integrated system of
intervention, measurements, and refinements of healthcare delivery
designed to optimize clinical and economic outcomes within a specific
population." The program relies on aggressive prevention of
complications and treatment of chronic conditions. It focuses on the
positive impact of appropriate interventions in delaying morbidity and
mortality among patients with diabetes, asthma, and HIV/AIDS. Patients
are referred by three primary sources, including monthly hospital
computer data that details visits by uninsured clients, a local "First
Call For Help" referral line, and local physicians.

Nurse Disease Managers, who encourage face-to-face meetings with
patients, act as their liaison among providers, scheduling appointments
and monitoring compliance. Intervention and patient education are
considered essential elements of the program, which incorporates
appropriate educational tools, including relevant written materials and
referrals to support groups and counseling, to encourage patients to
clearly understand and manage their health care program.

Nurse Disease Managers use a three-step approach to ensure patient care:

1.  *Assessing and Planning:* Nurses conduct an assessment of each
    patient's disease status and risk factors for complications,
    including patient history, results from a recent physical, and
    extensive lab work. The physician then works with the nurse manager
    to develop an appropriate health care plan.

2.  *Implementation and Delivery:* Nurses conduct a follow-up assessment
    to determine the patient's physical condition, lab results, and
    self-monitoring results and analyze patient compliance with
    established disease-specific guidelines for care.

3.  *Reassessment and Adjustment:* Patient progress is reassessed based
    on current information and adjustments to patient plans are made
    accordingly.

MHS uses multiple evaluation methods to measure progress and success
rates. Patient quality of life surveys are conducted at the point of
entry into the system and again six months after entry. Patient and
provider satisfaction surveys are conducted yearly. Lab results and
health care costs are also consistently monitored.

Access II Care

Christine Collins from Access II Care in Asheville, North Carolina
discussed her program's case management services, which are currently
offered to Medicaid patients diagnosed with asthma and diabetes and
patients who have been identified as high cost and frequent users of
health care services.

Access II Care's case management services are unique. Patients are
assigned by the DMA (Division of Medical Assistance) to participating
primary care providers (PCP) in a network. Case managers are then
assigned to participating practices and are often located onsite in the
primary care offices. Case managers provide services in three areas:

1.  *Population Management*: A disease registry is used to monitor every
    patient with a specific chronic disease. Chart reviews and limited
    outreach activities are conducted to ensure that each patient is
    receiving the care that they need through their PCP.

2.  *Benefits Advocacy*: A one-time intervention is offered to patients
    to remove a barrier to care, provide necessary health education, or
    inform them of their rights and responsibilities.

3.  *Case Management:* Case managers work with patients to address both
    their medical and psychosocial needs.

The key to Access II Care's success is provider participation. Providers
are involved in the development of disease management services and case
management standards. Facilitating participation can be a challenge.
Access II Care focuses a significant amount of attention and energy on
assisting practices in changing their practice patterns. The benefits of
implementing in-house case managers are frequently documented and
presented to providers. Ms. Collins had the following recommendations
for other communities attempting to increase provider buy-in:

-   *Partnership***:** Involve the physician in the decision-making
    process. Be open to their suggestions and allow for individualized
    adjustments.

-   *Pride*: Most physicians pride themselves on providing good care.
    Find an example of something that is working well in their practice
    and call attention to it.

-   *Responsibility*: Design a system that designates responsibilities
    for each member. Create a win-win situation. For example, ensure
    that case managers will ease the work load and find missing
    patients, and that the physician will adopt the same protocol for
    all patients.

-   *Feedback*: Provide specific, accurate data, including claims and
    random chart audits.

-   *Competition*: Share results from multiple providers in a
    non-threatening manner. This may encourage providers to equal or
    better their counterparts.

-   *Recognition*: Acknowledge successful programs. Even minor
    recognition such as gifts of chocolate provide encouragement for
    diligent work to continue.

-   *Provider Education*: Present important information to the provider
    in a convenient manner. Offering lunch provides a good ice breaker
    and allows time for discussion. Be sure to ask what the provider
    needs. Consider having a local expert deliver your message.

-   *Champion*: Locate the champions in each practice who will support
    your mission. A successful program requires the involvement of the
    entire staff, not just the physician.

-   *Simplicity*: Keep your message and program suggestions as simple as
    possible.

Lompoc Valley

Gail Nickerson from Lompoc Valley, California, joined the call to
discuss the case management software program that her collaborative is
currently using, Casewatch, a product of Automated Case Management
Systems, Inc. Lompoc developed its own assessment tool, surveys,
authorization forms and other forms that were integrated into the
Casewatch program. The result is a community health information system
that links hospitals, public health departments, care coordination
offices, and other providers into one automated system. The
collaborative has been very pleased with the system and is particularly
satisfied with the technical support provided by the developer. Ms.
Nickerson is available to discuss the program and its implementation in
greater detail. Her contact information is listed below.

Program Sustainability

Dr. Jack Epstein, a Family Physician and champion of Disease Management
protocols, presented ideas for designing disease and case management
programs for sustainability. Dr. Epstein has experience as both an HMO
and Health Center medical director and has facilitated disease/case
management sessions at CAP grantee meetings. The Flint Group, Dr.
Epstein's organization, is a health care consultancy that has authored a
curriculum in disease management for the Bureau of Primary Health Care,
and has worked with the clinician group that developed Evidence-Based
Health Care guidelines for Health Centers.

Dr. Epstein noted that several factors determine whether a case or
disease management program will prosper and continue after the grants
stop. The single best predictor is the ease with which a case management
program is implemented. If a particular program is difficult to
initiate, it may signal underlying problems that will prevent the
program from being successful in the long-term.

Dr. Epstein suggested the following questions to consider when designing
a disease or case management program for sustainability:

-   Who drives the program renewal decision?

-   Is there a budget for the program? Is it adequate to support the
    program's objectives?

-   Are there champions within the program and among the provider
    community who will drive the effort?

-   Will local hospital and university partners support your program?

Effective case management program design should reflect thoughtful
consideration of questions such as these. Dr. Epstein noted that the
reasons programs continue beyond an initial grant period are related to
either outcome or process measures. Measures to consider include:

> ***Outcome Measures***:

-   *Cost Savings* - The case/disease management program demonstrates a
    noticeable savings that benefits the entire initiative.

-   *Clinical Improvement* -- The case/disease management program leads
    to enhanced clinical services and operations.

-   *Patient Retention* -- Patients continue to participate in the
    program as a direct result of the case/disease management feature.

-   *Staff Retention* -- Staff members are directly benefited by the
    existence of the case/disease management program.

> ***Process Measures***:

-   The disease or case management program is recognized as an essential
    component of the entire initiative.

-   The program is a valued resource and solutions provider.

-   The program acts as a quality improvement auditor for an initiative.

-   The program facilitates network building among key partners.

Dr. Epstein recommends that these concepts should be addressed even
before the grant application is submitted. However, since many
organizations do not consider renewal until a case/disease management
program is already implemented and functional, Dr. Epstein emphasized
enhancing for sustainability at the earliest possible opportunity.

Many case/disease management programs have the potential to become a
permanent part of the care-giving process. A concise, credible story of
achievement backed by process and outcome data should influence both
internal and external directors of the program toward long-term
sustainability. The key to program longevity is to consistently
communicate its performance to the internal and external decision makers
long before the program is due for renewal.

Conclusion

As demonstrated in this discussion, case and disease management programs
vary considerably depending on the needs of the clients served.
Currently, there are no set guidelines for establishing these programs.
The CAP grantees who discussed their experiences provided valuable
insight about how to approach, implement, and monitor these beneficial
programs. For more information, please contact the call participants to
learn more about case management and the specific programs that were
discussed during this call.

For More Information

**SKYCAP**

Fran Feltner

Director, University of Kentucky Center for Rural Health

\(606\) 439-3557 x257

fjfeltn@pop.uky.edu

**Jackson Medical Mall Foundation**

Fleetwood Loustalot

floustalot@hindscoha.org

**HealthAssist**

Michelle Sawyer

MSAWYER@pcmh.com

**Broward County**

Sharon Zucci or Mike Deluca

mdelucca@brhpc.org

**Access II Care**

Christine Collins

Ccollins-a2c@juno.com

**Lompoc Valley**

Gail Nickerson

gnickerson@rosenworld.net

**The Flint Group**

Dr. Jack Epstein

Please contact Audrey Smolkin

asmolkin@hrsa.gov