Care management

In-clinic case manager brings additional skill set to Westside Health Center

A CareOregon pilot project places case manager within Multnomah County Health Department’s downtown Portland primary care facility.

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The patient is homeless and has a history of drug use. She has no phone, and doesn’t respond often to messages left for her at the downtown shelters where she sometimes finds a bed and a meal.

COPD and high blood pressure brings her often to the emergency room for episodes that could have been prevented, had she received regular treatment by a primary care provider.

But, blood pressure checks just don’t seem much of a priority when you’re hungry and cold and the source of the next meal and the night’s shelter is still unknown.

Debbie Root, RN, CCM, says she can help change that. For five years, as a case manager for the CareSupport Program she’s helped CareOregon members who are caught up in the complex web of medical and social services. Since January, she’s been working at Westside Health Center, piloting a program to place CareOregon case managers in clinics that have exceptional needs for their special set of skills.

Westside was a good fit for her, she says, having been one of her responsibilities since she started in CareSupport.

The CareSupport program provides support for members who have complex medical, behavioral, and social issues and are at risk of using emergency rooms and hospitals excessively, rather than getting more appropriate primary care.

Debbie’s work with members was primarily over the telephone.

“I would call members and see how I could help with navigating the system,” she says. “Helping them know what to do at appointments and how to get the best out of their appointments. Helping them understand and comply with their provider’s treatment plans.

“Sometimes providers or clinic managers would call and I’d work with their patients. Not all the patients know the societal norms.”

Debbie would act as a buffer as well as a bridge between the patient and the clinical staff, helping patient know what to do to get the best out of their health care, and helping clinic staff know how to get the best response from patients who have these particular circumstances.”

Debbie now brings these same skills to working directly with patients and providers in the clinic.

“I think that a connection is made a little quicker than over the phone,” she says.

Case manager expands the medical home team

Westside is a Primary Care Renewal clinic, where doctors, nurses, medical assistants and behavioral health specialists work in teams in a medical home environment. The purpose of a case manager is to supplement the teams by looking at different issues from a complementary perspective and working closely with the patients, says Rebecca Ramsay, BSN, MPH. Rebecca is senior manager of CareSupport and Clinical Programs, and Debbie’s CareOregon supervisor.

“Because Debbie doesn’t provide direct patient services, she is able to spend more in-depth time with each patient that she follows,” Rebecca says. “She assesses, educates, coordinates care, motivates, coaches on self management, provides anticipatory guidance and does medication reconciliation, among other responsibilities.”

This kind of program has been tried successfully in at least two other locations. Rebecca and Medical Director David Labby, MD, PhD, were aware of these programs through their association with the Institute for Healthcare Improvement and experience with medical homes.

“We decided we wanted to pilot it and Westside seemed to be the place to try it,” Rebecca says.

“The population served by Westside is quite acute,” she says. “Many have unstable housing, cognitive challenges, current substance abuse issues, in addition to complex medical conditions. We believe they will benefit from having a consistent person following them, monitoring them, and helping them between provider office visits.”

During the six-month pilot, Debbie will be able to do the things that can make treatment more effective, particularly in this population.

“She is also making home visits and hospital visits that the PCR team members cannot make as often because of the work they have to do in the clinic,” Rebecca says. “Debbie also has in-depth knowledge about our benefit structure and prior authorization processes. She can provide this expertise to her colleagues at Westside and streamline utilization management processes by being a go-between for our Medical Benefits Assurance unit and the Westside providers.

“Finally, she has over five years of experience doing complex case management therefore she brings a different perspective and new competencies to the PCR team,” Rebecca says. “My guess is that there will be a lot of learning back and forth between Deb and her clinical colleagues at Westside.”

“I think it’s going to blossom.”

Westside’s Clinic Manager Lynne Wiley and Nursing Supervisor Robin Bock welcome Debbie to the clinic.
 “I think we’re going to do well,” says Robin. “Debbie is very flexible and doesn’t need all the answers before stepping in.”

On a recent morning, Debbie accompanied a patient with mental health issues to the emergency room for care the clinic could not provide.

“Her presence makes a difference,” Robin says. It makes it easier for the emergency room staff when Debbie is there to help with the sometimes disruptive symptoms of mental illness.

Robin describes the difficulties that face home health workers with especially challenging patients. She recounts a case where the residence needed cleaning, the patient had untreated wounds, incontinence and no ability to cook, but refused to leave the residence. Debbie is able to help home health workers overcome those obstacles.

“It takes a little courage to step into those situations, know what the truth is, and advocate for that client,” Robin says.

Better efficiency, better outcomes

The theory behind the pilot is that by embedding the case manager into the primary care clinic, you gain some efficiency, Rebecca says. And by co-locating with the primary care team, you develop deeper relations with both the patients and the providers.

Results of the pilot won’t be known for nine to 12 months, but the team will be looking for reduction in unnecessary utilization (as measured by reduced hospital admission and readmission, and fewer emergency department visits), better quality of care and improved patient and provider satisfaction with care.

Even if the pilot is a resounding success, there is still a challenge to more wide-spread implementation: the number of people with the skills and experience to be successful.

• The Institute for Johns Hopkins Nursing offers an online program for this kind of work, called Guided Care Nursing. Rebecca and Debbie are taking the course.