Location:
Problem
Addressed: Access to Long-Term Care and
Rehabilitation Services
Healthy
People 2010 Objective: 1
Web
Address: www.pardeehospital.org
To
address the range of health and human service needs of an increasing aged and
chronically ill population,
THE
MODEL
Blueprint: The purpose of the case management program is to assist those individuals
at high risk for repeated health care encounters to obtain community services
at a lower level of care, averting the health crises and higher cost of care. The
program helps frail adults over age 45 remain independent, safe, and in their
home and community for as long as possible by facilitating aging in place. The
program addresses the medical, psychosocial, pharmacological, functional, and
spiritual problems of those over age 45 via an outpatient case management
program under the auspice of the
While
the focus of the program is on delivery of services in the client’s home, services
are also delivered at the physician’s office and community agencies. These services
include:
·
medication management;
·
cognitive activities of daily living (ADLs), instrumental ADLs, and
nutritional screenings;
·
coordination of services and resources;
·
assistance with completion of applications for various government
programs (Medicaid, Social Security, disability);
·
accompaniment to patient’s doctors’ appointments;
·
emotional support; and
·
empowerment for greater client involvement in decisions related to access
to and receipt of health services.
The
case managers provide in-home visits to assess needs and coordinate services,
provide ongoing contact with agencies and physicians, and share information
(upon client consent) with referring agencies. To manage the data, the program
initially utilized special software to shared information across agencies;
however, the software was unable to meet the program’s needs and expectations
and was abandoned in favor of continued use of phone and other communication
avenues. Despite these drawbacks, technology is important to the program’s
success. Each case manager has a cell phone, pager, and laptop computer for use
in entering clinical notes and patient information. The program has also
purchased 10 telemonitoring units that can be used for rural clients. These
units allow case managers to have contact with isolated clients between visits.
Making a
Difference: Since the
1980s, the
CBCM has been successful in meeting and exceeding
program goals. Key to reaching program goals has been the development of an
assessment instrument to identify those clients at high risk for
institutionalization. The characteristics placing clients at risk for
institutionalization include the inability to perform ADLs, lack of a primary
care physician, lack of information referral and access, and nutritional and
cognitive deterioration.
Program outcomes include reductions in emergency
room (ER) visits and acute care hospital stays, improvement in nutritional
assessments, lowered deterioration in cognitive and ADL scores, and positive
feedback from physicians and referral sources. Over a two-year period, the
program demonstrated a 43 percent reduction in ER visits for clients, a 44
percent reduction in hospital admissions, and a 39 percent reduction in acute
days of stay. Over this same period, the hospital saved $169,012 in cost of
care by reducing acute care utilization. The advantage of this program compared
to other senior programs is its focus on following clients over the long term—until
either the client is placed into a facility on a long-term basis, the client or
family chooses to remove the client from care, or upon the client’s death. The
program continues to grow and evolve, with many of the original members of the
steering committee remaining active. Although the original grant funding ended
in 1998, the board of directors recognized the program’s success and voted to
continue the program with funding from the
Beginnings:
Dr.
Challenges
and Solutions: The
program has faced a number of challenges ranging from technical to financial. The
initial software program developed for CBCM did not meet expectations due in
part to technical problems in sharing information among agencies. Secondly,
matching professional resources with the growing demand continues to be a
challenge evidenced by the growing waiting list to receive services. Financial
concerns remain a consideration as well. While the program was initially funded
through a grant from the Duke Endowment Program and later from the Kate B.
Reynolds Foundation, both grants have expired, and the program is solely financially
supported by
The CBCM program reaches the community through a
variety of avenues including referrals from physicians, families, and agencies.
The program has developed a brochure describing its services, is publicized
through the hospital’s marketing department and website, and utilizes more
traditional marketing approaches such as newspapers. CBCM representatives also
participate in community agency meetings and attend regional and state
conferences and programs. In Spring 2004, the program was recognized by the
Duke Endowment of the South Carolina Hospital Association as a Geriatric Best
Practice.
E. Keith Ford, LCSW
Phone: (828) 696-1152
Fax: (828) 696-4657