Visibility is the embedded case manager's greatest asset.
For Ms. Fox's team of case managers embedded in seven primary care practices and two work sites, outreach is mostly telephonic, but may also include visits to patients' homes if they see the need.
"We will do anything to make sure patients get to where they need to be. A lot of our home visits occur because of confusion with medications," she explained during Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a September 2014 webinar now available on-demand.
Typically, the embedded case management team averages about a thousand outreaches per month, Ms. Fox estimates. Telephonically, they reach almost all patients within 48 hours of discharge, and most ED discharges, running down a multi-item checklist, from medication and home health needs to scheduled follow-up appointments and advanced illness management (AIM), formerly referred to as palliative care, which was frequently misunderstood as strictly hospice, she noted.
Caldwell is working to establish that reporting linkage with skilled nursing facilities as well.
Medication is a large part of that telephonic conversation, Ms. Fox adds, as is a focus on new Transition Care Management Codes, where practices can be reimbursed for non-face-to-face care provided when patients transition from an acute care setting back into the community.
The visibility of embedded case managers in a practice is a great asset to both providers and patients, she says. "We seem to be more accepted by providers, staff and patients because they see us as part of the team."
At the two work sites, the case manager works alongside a nurse practitioner, where the goals are preventive care and chronic disease management.
With extensive RN experience in home health and schooled in the Geisinger Healthcare System model of embedded case management known as ProvenHealth Navigator℠, Ms. Fox joined Caldwell three years ago to develop and launch the program. Referrals to embedded case managers come from hospital discharge and ED reports, as well as provider and even self-referrals.
Although relatively new, Caldwell's embedded case management approach has helped to halve 30-day hospital readmissions in its Medicare population— from 19.16 percent in second quarter 2012 to 9.09 percent in fourth quarter 2013, she said. Buoyed by this success, Ms. Fox's team is targeting ED visits as its next metric.
During the program, Ms. Fox also shared six qualities of an effective embedded case manager, advantages of embedding case managers in care sites, and tactics for engaging physicians and staff in the embedded model.
Click here for an interview with Melanie Fox.
