Embedded care managers prove their worth for payers, patients

Key Points

EMBEDDED CARE MANAGERS increasingly are becoming members of clinical teams in physician offices. They might conduct comprehensive evaluations or call attention to neglected health issues, such as preventive care screenings or vaccinations, making care more effective and efficient.

In 2007, Aetna piloted a program that placed nurse case managers in 36 primary care practices to help manage patient care. At the time, the concept of embedded nurses-case managers, care managers or health coaches-was revolutionary. Instead of anonymous individuals communicating with physicians and their patients by telephone, insurers moved RNs, social workers or behavioral health specialists into physician offices to work face-to-face with staff and patients.

Aetna's telephone case management program produced a 31% reduction in the number of acute-care days compared to fee-for-service Medicare, while the embedded case management program produced an additional 8% to 12% reduction in acute-care days over the four-year program.

While the embedded nurses serve only a small percentage of Aetna's members, Dr. Krakauer says there are plans to aggressively grow the program to reach half of its members through embedded case management programs within the new few years.

PRINCIPLES OF ENGAGEMENT

Glen Stream, MD, president-elect of the American Academy of Family Physicians (AAFP), says with the focus of healthcare reform on value-based purchasing and better quality, embedded case management programs have the potential to improve care across the continuum.

"The concept of engagement, responsibility and accountability for patients is part of primary care and is an evolving concept central to the principles of the patient centered medical home transformation," Dr. Stream says.

AAFP eventually wants to see embedded case managers in all primary care offices. Dr. Stream, who practices in Spokane, Wash., says embedded case managers are known as "wilderness guides" in the Pacific Northwest.

"The health system is the wilderness for patients," he says. "To help patients navigate the system to their best advantage-maintaining good health and wellness-does take care coordination, and it's best done in the setting of the medical practice."

He says there's an advantage to the care model: better patient care and better physician satisfaction. In the long run, it's also more cost efficient for the payer.

The embedded case management model also transforms the medical practice by moving the physician away from the role as sole care provider, creating a team model in which everyone is practicing to the potential of their license.

"For nurses, reaching out to patients over the phone and doing care coordination is clearly within their scope of practice and training, and they can do that where the physician doesn't have time in the day," Dr. Stream says.

AmeriHealth Mercy's Keystone Mercy Health Plan, a managed Medicaid plan in Pennsylvania, recently was recognized by Medicaid Health Plans of America for its embedded care manager program. Through the use of informatics and care managers, the program resulted in a 17% reduction in hospital admissions and a 37% drop in inpatient lengths of stay.

The Pennsylvania-based program originated three years ago from discussions between Keystone and Mercy Health System on how to work collaboratively to serve a key geographic area with an impoverished and underserved population. Currently the program serves 489 members at the Mercy Ambulatory Care Clinic, located in West Philadelphia.

"It was a way for us to immediately share information between the office and the health plan," says Karen Michael, vice president of Clinical Services for Keystone Mercy Health Plan. "We have information a mile wide and an inch thick. The physician practice has the opposite view-they have information an inch wide and a mile deep. They know what's happened in the office and with connected providers, but they don't know what happened to members outside of the system."