Healthcare Intelligence Network

Physician engagement is step one in the process of embedding case managers, says Robert Fortini, VP and chief clinical officer at Bon Secours Health System. There is much value in embedding a case manager in a primary care practice, including their influence on patients’ medication compliance. Prior to presenting for HIN’s August 10 webinar on Embedded Case Management in the Primary Care Practice: Program Design and Results, Fortini discussed preparing a practice for the arrival of a case manager.

HIN: How do you prepare a physician practice for the case manager’s arrival so that a supportive environment is created?

(Robert Fortini): We don’t do anything at the practice level until we have provider engagement. Any changes that are made to the workflow are thoroughly vetted through the entire provider staff — whether mid-level or physician — and we get consensus and agreement. Typically, we have an initial meeting where everything is thoroughly explained about the case manager’s role; everyone is given a copy of the job descriptions and workflows, protocols, goals and objectives, as well as competency checklists. And everybody is thoroughly prepared in advance.

Only at that point when we have consensus from the providers, do we then proceed with the HR hiring action. By the time that’s complete and the person gets on board, the practice is completely prepared for their role.

HIN: In the January issue of the “Healthcare Finance News,” you were quoted as saying that “newly formed Bon Secours care teams of doctors and nurses and the embedded case managers would do workflow rehearsals to make sure that all teams were performing care uniformly.” Can you talk about these rehearsals and any issues or challenges that they identify?

(Robert Fortini): This concept is more of a structured manner of doing an old concept. Not all the rehearsals are pertinent to the case managers. One of the workflow rehearsals is for a standard rooming protocol for support staff. In this particular event, we’re using EPIC, an electronic medical record platform. We will rehearse with a medical assistant or a licensed practical nurse (LPN) responsible for rooming the patient what the minimum data set to be captured will be. We want to make sure that weight and height is recorded, so BMI is calculated. We want to make sure that tobacco cessation screening and counseling are addressed. We want to make sure their vital signs are done appropriately, that a past medical history and past surgical history is captured, that medication reconciliation occurs, and that refills that are due are pended for the physician to sign. This way, by the time a physician gets in the room, all the busy work is done and most of the documentation has already been started. This streamlines the physician’s role. As you can see, a case manager might not be engaged in that workflow.

Another workflow that we rehearse is the concept of a daily huddle. This is literally a team meeting at the start of the day that runs for 7-10 minutes in the hallways that we expect the case manager to be a part of. This is a review of the day’s schedule — what’s coming in that day. This way, every member of the team is prepared in advance, including the case manager, who might have specific case management functions. For example, with an elderly patient coming in at 10 a.m. with multiple co-morbidities, poly-pharmacy and who is struggling, the expectation is that the physician is going to come in and address immediate medical needs and build a relationship with that patient.

But before the patient leaves the practice, he or she will sit with the case manager for medication management and adherence education. This is why the RN case manager should be prepared in advance for what’s coming in that day. The other value to that is that the immediate clinical support staff is also prepared. They all know in advance if that patient needs to have an EKG done. And so before the physician gets in the room, the EKG has been performed and the results are available for interpretation. It streamlines the visit and improves the efficiency.

The specific workflow can get more sophisticated as the team matures. Those are standard workflows. But then we have disease-specific protocols that we also rehearse with the staff.

HIN: To add to your response, are all of these workflows, especially the more specific ones, documented?

(Robert Fortini): Absolutely. We have a protocol for each one. And the expectation of performance is very clearly established with the staff; this is what the staff will do every single time a patient arrives.

HIN: You also said in the article that medication compliance would be a focus of these care teams. Do the embedded case managers have any duties in this area?

(Robert Fortini): Yes, and the example that I just used in my answer to the second question illustrates this. It is not uncommon, especially in a well-established internal medicine practice, for the needs of the geriatric patient to be prominent. Usually that means poly-pharmacy. If you’ve ever been in a situation where you’re taking more than two or three medications a day, it can be confusing. That 20 minutes of education that the case manager will perform with the elderly patient about what each medication does and how they should be taken is invaluable. We go right down to the basics. The case managers also set up pillboxes with the patients to help make complying with a medication regimen simple.

That’s just one illustration of medication compliance. We acknowledge the fact that 30 percent of all prescriptions are never filled and that of the remaining 70 percent, probably half of them are taken incorrectly, pills are split or days are skipped. Compliance with a medication record is of paramount importance for managing a chronic illness, and in certain categories, preventing readmission.