“What we’re talking about is the insertion of new personnel who didn’t exist before,” he says. “It means more time spent with the hospital discharge process, or maybe following the patient to the rest home. It’s a recognition that readmissions may represent that someone did a poor job of making sure the patient got the care he or she needed after they left the hospital.”
Wachter says that the case management model that was popular in the 1980s and ’90s didn’t work because it wasn’t really connected with the patient’s primary care physician. What these multiple chronic disease patients need is face-to-face contact with a trained professional who convinces them they’re on their side. This is the kind of professional who has the authority to follow up with every aspect of the needed care, including dealing with the patient’s depression, if it seems to impede the ability to follow instructions, Wachter and others suggest.
Geisinger’s ProvenHealth Navigator was one of the earliest adopters of this system that has shown success, says Janet Tomcavage, RN, MSN, vice president of health services for Geisinger Health Plan in Danville, PA.
In a paper published in the August 2010 issue of the American Journal of Managed Care, Tomcavage and coauthors said they found that the project “was associated with an 18% cumulative reduction in inpatient admissions and a 36% cumulative reduction in readmissions across the total population of the study period.”
Tomcavage explains that physicians alone don’t have time to perform the kind of follow-up care to make sure patients get the kinds of screenings and tests they need. And so far, after attempting this strategy with more than 15,310 Medicare Advantage patients enrolled in the Geisinger health system, there has yet to be a physician push back “because at the end of the day, the case manager ends up saving them time,” she adds.
Today, 80,000 patients are served by Geisinger’s medical home model.
But it isn’t easy. “This is hard work,” Tomcavage says. “It takes someone who wakes up every day and drives it, and it cannot be ambiguous. There needs to be dedicated leadership that doesn’t do anything else, because the challenges for physician/staff engagement and workflow redesign are there. You need committed physician leadership for these to work.”