Navigator Tools Leading to Superior Patient Outcomes

Susan Rogers, RN-BC, MSN, CCMRPG (Rogers Professional Guidance,

LLC)susan@4casemanagement.com

Disclaimer• Not a CMSA or CCMC program • Based on my personal experience • My intellectual property

Objectives• Describe population management and the needs

for the future• Identify opportunities to grow with changing times

through collaborative relationships• Discuss trends in health care that directly affects

every case management process

Bibliography• Communities Shaping a Vision for America's 21st Century Health & Healthcare,

Background "White Paper“, Wye River Group, www.wrgh.org• Crossing the Quality Chasm, Institute of Medicine's report from March 2001• Fink-Samnick, E., Owen, M., Rasmussen, T. 5 ways case manager contribute to a

hospital’s bottom line. ASC Communications. Retrieved March 2013 from http://www.beckershospitalreview.com/quality/5-ways-case-managers-contribute-to-a-hospitals-bottom-line.html

• http://remingtonreport.com/news-across-the-healthcare-delivery/1305-9-health-care-reform-changes-2012

• Mullahy, C. M. New Health Care Models Raise the Ethics Bar for Case Managers, Care Management, Feb/March 2013, 7-28. Growth of ACOS Not Just Medicare-related. http://remingtonreport.com/index.php

• http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

• http://commonwealth.communitycarenc.org/toolkit/11/default.aspx • http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853• http://www.healthypeople.gov/2020/about/DefaultPressRelease.pdf• http://www.cdc.gov/chronicdisease/overview/index.htm• Peter J. Cunningham, Center for Studying Health Systems Change, calculations using

2001, 2006, and 2008 Medical Expenditure Panel Surveys, presented at The National Academies Workshop on Measuring Medical Care Economic Risk, September 8, 2011.

• Medicare Blue Book• Communicate Health www.communicatehealth.com• Ask Me 3. http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3• CMAG, www.cmsa.org• Commission for Case Management Certification, www. Ccmcertification.org

Crossing the Quality Chasm: A New Health System for the 21st Century

1. Care is based on continuous healing relationships. Always available – telephonically or web

2. Care is customized according to patient needs and values.

3. The patient is the source of control. Information and opportunity in order to control Patient preferences and encourage shared

decision making.4. Knowledge is shared and information flows freely. 5. Decision making is evidence-based. 6. Safety is a system property. 7. Transparency is necessary.

Provide all information needed to make informed decisions

8. Needs are anticipated. 9. Waste is continuously decreased. 10. Cooperation among clinicians is a priority.

Institute of Medicine's report from March 2001

Chronic Disease Prevalence• Leading cause of death• 7 out of 10 death• In 2008• 107 million or 1 out of ever 2 adults• 1 of 6 reported chronic illnesses

• Cardiovascular disease• Arthritis• Diabetes• Asthma• Cancer• Chronic obstructive pulmonary disease

(COPD)http://www.cdc.gov/chronicdisease/overview/index.htm

Prevalence of High Out-of-Pocket Burdens Among the Nonelderly, by Chronic Condition Status, 2001, 2006, and 2008

Note: Percentages include health insurance premiums.

Source: Peter J. Cunningham, Center for Studying Health Systems Change, calculations using 2001, 2006, and 2008 Medical Expenditure Panel Surveys, presented at The National Academies Workshop on Measuring Medical Care Economic Risk, September 8, 2011.

Percent with Total Burden > 10% of Income

Population

• Living longer• Seniors working

• Generally healthier • Disability may be declining but chronic conditions increasing• More uninsured• Baby boomers coming of age• Retiring not prepared for health care costs • More savvy – internet prepared – but don’t ask

questions• 8 in 10 search for healthcare info• Peer to peer healthcare

Prices for medical services can vary• Chicago, IL prices for an MRI of the lumbar spine

with contrast ranged from $500-$2,661 among three hospitals and five imaging centers.• In Washington, DC prices for routine

mammogram screenings ranged from $123-$441 among community based center & hospitals

(source: Healthcare Bluebook)

Transparency

Disparities

• Total population in U.S. 304 million (2008)• 33% racial or ethnic minority population• 51% women• 12% people NOT living in nursing

homes/residential care with a disability• 23% or 70.5 million persons lived in rural areas• 77% or 233.5 million persons lived in urban areas• In 2002, 4% of population 18-44 identified

themselves as lesbian, gay, bisexual or transgender

http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx

9.5%

18.7%16.5%

23.0%

12.7%

Percent Uninsured, Ages 55-64, by Race/Ethnicity, 2006

DATA: March 2007 Current Population SurveySOURCE: Kaiser Commission on Medicaid and the Uninsured estimates.

33%

White, Non-Hispanic

Hispanic African American, Non-Hispanic

Asian/Pacific Islander

American Indian/Alaska Native

Two or More Races

ACO vs. IDS Opportunity and Responsibility• Integrated delivery system (IDS)

• A network of health care organizations under a parent holding • Multiple levels of services to include physicians and hospitals• Sometimes under on Electronic Health Record (EHR) • May chose to be an ACO.

• Accountable Care Organizations (ACO) • According to CMS is “an organization of health care providers that

agrees to be accountable for the quality, cost and overall care of MC beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it”

• Payment linked to performance and cost-containment• 33 core quality measures based on five domains• The patient/caregiver experience• Care coordination/patient safety excluding pps-exempt cancer

hospitals and med treatment of cancer not 30 day readmission rule

• Preventative health measures, i.e., breast cancer• Delivery of services to at-risk populations , i.e. heart disease

and diabetes

Physician Groups• Medical Home

• Primary Care Physicians – may be a substantial investment• Improve patient satisfaction, care and outcomes• Care coordination a large part• Hospitals 15% to 20% reduction in readmissions• 10% fewer admissions and 20% ER visits• Derived from DoD policy before ACA• Evidence based treatment for improved outcomes – CM ethics

• Health Information Technology (HIT)• Medical homes require a broader use• CM ethics – text, email etc.

Mullahy, C. M. New Health Care Models Raise

the Ethics Bar for Case Managers, Care Management, Feb/March 2013, 7-28

Community Care of North Carolina• Medical Home Model• Network• Care Improvement Strategies• Care Management• Disease Management• Chronic Care• Primary Care and Behavioral Health Integration

So Much MoreCommunity Care of North Carolina• Full community process• Population Management – Advanced Practice

Nursing• Evidence based – comprehensive – resource mgmt – cont

of care – health promotion

• Care Coordination – Integrated Care Model• Use of telemanagement and clinic visits• HF 14% readmission with ICM• 32% readmitted without

• Patient Centered• Provider Buy In• Telemedicine• Quality and Cost Effective

http://commonwealth.communitycarenc.org/toolkit/11/default.aspx

Synthesis Project• Patient selection. Successful programs work with patients whose

needs are complex but not so severe that only palliative care is appropriate.

• Person-to-person encounters, including home visits. Care management performed via telephone without in-person contact was not successful for complex patients.

• Training. Care managers who receive adequate training provide services more efficiently and have more manageable caseloads. One successful care management program cited in the report maintains an active care manager caseload of 50 complex patients.

• Multidisciplinary teams. When care managers and physicians work as a team, care management improves. Co-locating care managers and physicians in primary care practices may be a key to increasing physician involvement in the team model.

• Family involvement. Successful programs engage informal caregivers in the home to work with and support care managers.

• Coaching. Teaching patients and families self-management skills helps them identify early warning signs of worsening disease conditions so emergency room and hospital visits can be prevented.http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf49853

Health Literacy

Ask Me 3

• What is my main problem?• What do I need to do?• Why is it important for me to do this?

http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/

Patient’s Bill of Rights• Care must be:• Individualized• Patient/family centered• Considerate• Respectful

• Client must be:• Well informed (informed consent)• Educated about diagnosis, prognosis and treatment/care

• Client has right to:• Self-determination ( refuse treatment)• Living Wills• Advanced Directives• DNR

Critical component to transitions of care

Management of Medications

Case Management Adherence Guide 2012 - New release- $10 download to

pdf- Presentation

requests are now being taken.

Incidence of Medication Noncompliance

50% of the 1.8 billionprescription medications

dispensed annually in the United States are not taken

correctly by patients Adherence to Long-Term Therapies: Evidence for Action. WHO 2003

U.S. Patients Do Not Take Medications as Prescribed

100%76%*88%

47%*

Rx prescribed Rx continuedRx takenRx filled

-12%-12%

-29%

* 22% of U.S. patients take less of the medication than is prescribed

1.American Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27, 2002.

Biomedical PsychosocialBiomedical Psychosocial

• Patient centered• Information exchange• Patient “saves” self• Negotiate behavior• Adherence• Servant• Assess motivation• Understand, accept• Resistance is information• Confront• Respect earned

• Practitioner centered• Information giving• “Save” the patient• Dictate behavior• Compliance• Authoritarian (P-C)• Motivate the patient• Persuade, manipulate• Resistance is bad• Argue• Respect expected

Navigation of the Healthcare System

Definitions of Case Management

• A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes…CMSA

• Oncology Nurse Navigators are defined as cancer and cancer system trained individuals who facilitate timely access to appropriate healthcare and resources for patients and their families. Navigators are skilled communicators who provide holistic care, empowering patients with education and knowledge about their illness.

Case Management Process

• Client identification and selection - Screening• Assessing and problem/opportunity identification• Stratifying Risk• The process of categorizing individuals and populations according

to their likelihood of experiencing adverse outcomes (e.g., high risk for hospitalization) (CMSA, 2010, p. 26)

• Planning – long and short term goals both CMs and Patients

• Implementing and coordinating – Action step of planning• Following up• Transitioning (transitional care) Appropriate termination.• Communicating post transition• Evaluating

Benefits, Outcomes,and Return on Investment• “Timely” access to healthcare and resources• Empowered shared decision-making education,

impacting patient choices and decisions• Improved patient and provider satisfaction• Decreased patient anxiety• Reduced treatment delays• The ability to ensure follow-up for mammography

screening centers with remote access interpretation.

Making the Case for Nurse Navigators. http://www.accc-cancer.org/oncology_issues/articles/SepOct2011/SO1

1-Desimini.pdf

• Wellness• Employer benefit• Smoking cessation > Obesity???

• Population Management• Promotion/prevention• Screenings• Cultural aspects coupled with belief system• Predictive Modeling

• Health Coaching• Transition Coaches

Many Pathways to Outcomes

Drill Down • Access to care – least restrictive environment• Right care, right patient, right time, right resources

• Quality • Cost-effectiveness – hard vs. soft savings, FTE

CMs• Cost benefit analysis• Return on Investment (ROI)• Value = Quality/cost

• Safety• Risk management

• Evidence-Based Practice• Research and research utilization

Outcomes: More Than Data

• Outcomes• Care – health related• CM intervention related• Education• Empowerment• Promoting adherence - CMAG• Care coordination• LOS

• Health literacy • Cultural diversity and competency• Interpreter choice• Belief system

• Motivation – readiness to change or adapt

Quality

• Hedis• Breast Cancer Screening 2014

• Guidelines/Research• Patient prevention/screening• Treatment guidelines • Palliative Care• Quality of pathology/staging• Prevention in the community

Patient-Centered Quality• Quality of information available and shared• Shared decision making• Coordination of care – warm hand offs• Management of treatment and complication• Satisfaction of EOL for patient and family• Timeliness• Safety• Efficiency• Over-utilization of testing or LOS in hospitals

• Vulnerability of community

Ways to Improve Hospital Performance• Improving outcomes

• Making patient appts• Coordinated transitional care

• Reducing readmission risks• “Keen focus on improving care coordination and eliminating gaps in care” -

CCMC

• Eliminating avoidable days• “Care management and care coordination” – NovaHealth• “ 50% fewer hospital days per 1000 patient and 45% few admissions” -

NovaHealth

• Enhancing claims management• Ensuring stay is medically necessary and advocating for patient

• Boosting core competencies• Preventative care for chronic diseases• Motivation

Fink-Samnick, E., Owen, M., Rasmussen, T. 5 ways case manager contribute to a hospital’s bottom line. ASC Communications. Retrieved March 2013 from http://www.beckershospitalreview.com/quality/5-ways-case-managers-contribute-to-a-hospitals-bottom-line.html

http://pfizer-architools.com/ArchiTools/

GREAT NEW TOOLSET

Evidence Based Interventions• Care Transitions InterventionSM (Eric Coleman)• Transitional Care Model (Mary Naylor)• Better Outcomes for Older Adults through Safe Transitions or

“BOOST” (Society of Hospital Medicine)• Geisinger• Best Practices Intervention Package for Transitional Care

Coordination (Home Health Quality Improvement Initiative) – cms.gov

• Interventions to Reduce Acute Care Transfers or “INTERACT” (Florida Atlantic University)

• STate Action on Avoidable Rehospitalizations or “STAAR” (Institute for Healthcare Improvement)

• Re-engineered Discharge or “Project RED” (Boston University)• Geriatric Resources for Assessment and Care of Elders or “GRACE

Team Care Model” (Indiana University)• Bridge Model of Transitional Care (Illinois Transitional Care

Consortium).

Susan@4casemanagement.comThank you!!