The FirstHealth Care Management Model
FirstHealth of the Carolinas, a comprehensive rural health care system based in Pinehurst, North Carolina, has developed an innovative care delivery model to effectively manage high-risk patients with chronic disease. This model, referred to as the FirstHealth Care Management Model, was developed and is delivered by the organization’s home health care entity and includes three major components:
1. Evidence-based standards of care or Pathways
2. Innovative technology, including video-enabled telehealth remote monitoring and smart phone applications
3. Customized, disease-specific education and support that aligns with the principles of health literacy and patient activation.
The FirstHealth Care Management Model is delivered by a highly functioning, specially trained, multidisciplinary team that is paid through an innovative performance-based compensation plan.
Specifically designed for the management of high risk, complex patients with chronic disease in the home health setting, the Care Management Model is also the foundation for the FirstHealth Complex Care Management program for chronically ill patients who are not eligible for home health care per federal guidelines but still require ongoing support, monitoring and education.
Home Health and Complex Care Management form the foundation of a population health strategy for high risk, high utilizing patients that is effective, sustainable and replicable.
Pathway-driven, Patient-centered Care
Chronic Disease Pathways are standards of care that provide a road map for the clinician and ensure that patients receive consistent and evidence-based care. Pathways incorporate clear, consistent patient education, are designed to enhance self-management skills and reinforce patient self-monitoring of conditions through technology.
Pathway standards were designed for heart failure, COPD, diabetes, and physical and occupational therapy for heart failure and COPD. Annually, approximately five hundred patients receive home health care utilizing the chronic disease Pathways.
The evidence is clear that the best approach to chronic disease management is to teach patients self management skills. Patients who know how to effectively manage their own health have better outcomes and a better quality of life. Though self-management skills can be taught, not all clinicians teach in the same way or teach the same content. Thus, the clinical practice variation can be significant. This has the potential to create confusion among patients or gaps in their understanding of their disease and effective self-management approaches. Standardized Pathways address this issue by ensuring that each patient receives consistent, evidence-based education in a way that they understand and can incorporate into their daily lives.
To ensure standardized educational content, disease specific video clips are delivered via telehealth technology. Patients complete an electronic post-test to verify understanding and to identify for the clinician content that may need further reinforcement.
Zone Tools also ensure clear, consistent content. Using the Zone Tool, the patient is taught how to identify if they are in the Green, Yellow or Red Zone. If the patient feels well and vital signs are normal, the patient identifies as being is in the “Green Zone.” If the patient is experiencing an increase in symptoms, for example, more shortness of breath, the patient would report being in the “Yellow Zone.” Finally, for patients that are experiencing extreme symptoms as taught in the Tool, such as chest pain, the patient would identify as being in the “Red Zone” and call 911 to seek emergency care.
Additionally, each clinician asks the patient what Zone they are in during every visit and every phone call, further reinforcing self management skills and the patient’s ability to identify their own symptoms and take appropriate action. Using the Zone language provides an easy way for the patient and clinician to communicate about the patient’s health status.
To support self-management and reinforce education, telehealth remote monitoring is also integrated into the Pathways. By having the patient send their vital signs data to the FirstHealth Center for Telehealth daily, as well as having the patient measure his or her own vital signs during home visits, the patient is engaged more often in self-care. The patient also begins to more clearly understand the relationship between their behavior and their health. For example, a patient sees a weight gain a day after a salt-laden meal, connecting behavior with health status.
Video enabled telehealth allows the clinician to complete a virtual video visit with the patient when appropriate, a powerful and effective alternative to a time consuming and costly home visit.
The Activated Patient
The Patient Activation measure or PAM, licensed by Insignia Health, is administered electronically to every Pathway patient at the beginning of care and at the end of care. The PAM is an evidence-based measure of the patient’s knowledge, skills and confidence in managing their own care. This is critical information to understand when working with patients with long term chronic illnesses. According to PAM-focused research, lowly activated patients tend to be frustrated, negative and unaware that they have any control over their own health. When teaching these patients, FirstHealth staff keep information simple and to the point. Since these patients are often already frustrated, too much information has the potential to increase frustration rather than lessen it. In the case of a lowly activated patient, simple skill building tools like a weight log or food journal is often an ideal first step. Once the patient succeeds in completing a simple self management skill, their confidence improves. Additional tasks can be added in increasing difficulty building one success upon the other. As the patient’s confidence rises, so does their ability to self manage as does the activation score. The PAM is patient centered because it meets the patient where they are, building their confidence at their own pace and moving towards effective self management.
The Teach Back method is used throughout the educational process. Teach Back is the evidence-based way to verify a patient understands what has been taught. Asking the patient to repeat what they have just learned requires the patient to put it into their own words. Teach Back gives the clinician critical feedback as to the level of patient understanding and cues as to the need for review or the readiness of the patient for additional education.
Finally, all educational approaches and methods also take patient’s health literacy levels into account. Studies show that patients with low health literacy are less likely to manage their chronic condition effectively or seek medical help when indicated and have higher hospitalization rates. Using plain language and clear visual tools are effective for patients with low health literacy. With this in mind, deliberate efforts are made to ensure that education and information is provided in alignment with a patient’s ability to obtain, process, and understand health information. Because of the prevalence of low health literacy, all patient education materials are appropriately designed.
Advanced Illness Management
The Pathways also incorporate the principles of Advanced Illness Management or AIM. These principles include advanced care planning and active symptom management for patients with complex, chronic disease. A key strategy is to identify what symptoms are the most problematic and stressful for the patient. Again, this patient centered approach focuses on what troubles the patient the most. For example, shortness of breath most likely causes extreme anxiety and fear. Once the clinician identifies this and offers solutions that empower the patient to manage their own symptoms more effectively, the patient begins to understand that they can have more control over their illness then they ever realized. This can reduce anxiety and improve the quality of life for patients with life limiting illnesses. Accordingly, a patient-centered care plan includes very specific interventions to help manage the symptoms the patient is experiencing.
As part of a holistic approach to patient care, the Pathways also focus on improving the patient’s functional, nutritional and clinical status using very specific nursing, physical and occupational therapy interventions. While the underlying disease cannot be cured, targeted strategies can significantly improve the patient’s quality of life. For example, the Occupational Therapist works with heart failure patients teaching very specific, standardized interventions to help mitigate their shortness of breath, again empowering the patient to mitigate their own care.
Transitioning to the Next Level of Care
The Pathways are designed to transition the patient home from the hospital and provide targeted, holistic support during those critical first few weeks. A series of specific risk assessments completed on the admission visit identify issues to be addressed in the care plan. Prior to discharge from Home Health or Complex Care Management, patients are assessed for eligibility for the next level of care. At the completion of the Care Management Program, referrals are facilitated to Pulmonary Rehabilitation, Cardiac Rehabilitation or the Diabetes Self Management Program to provide additional support and education and to further the goal of the highest level of self-management.
The Care Delivery Team
To ensure continuity and accountability, FirstHealth uses the multidisciplinary team concept as part of its care delivery model. The geographically designed team manages 60-70 patients and consists of 2-3 Registered Nurse Care Managers, a Physical Therapist, Physical Therapist Assistant, a Home Health Aide and a shared Occupational Therapist and Occupational Therapist Assistant. Patients are assigned on admission to the team and remain with the team until discharge. Patients may not be assigned outside of their team, so the team has to work together to meet the patient’s needs. The team fosters collaboration, coordination and an equitable sharing of the workload. Clinicians and patients alike benefit from a consistent team approach to delivering a comprehensive plan of care.
Defined e-mail groups allow communication to the patient’s team via their smart phones. For example, if a patient falls, the team is notified by e-mail in real time, everyone who needs to know knows what is going on and can reinforce falls prevention and safety precautions during their visits. The team model is designed to make every visit count no matter the discipline. The team is responsible for delivering a comprehensive plan of care.
The RN Care Manager heads the patient care team and is responsible for developing the patient centered plan of care. Accountable for all patient outcomes, the Care Manager mobilizes the team to achieve the patient’s goals. With the addition of smart phone enabled, video capable telehealth technology, the Care Manager is also responsible for reviewing all patient data and coordinating all interventions. This shifts the traditional responsibility of the Telehealth Nurse to the front line Care Managers and reduces unnecessarily fragmented care.
Creating a High Performing Team
No single component of the Care Management Model is more important than the development of a clinically competent multidisciplinary team. The team members must be highly skilled clinicians, effective communicators and decisive critical thinkers. To foster the development of an effective team leader, FirstHealth places a strong emphasis on providing new Care Managers with a comprehensive orientation program with required milestones – an orientation that spans the first twelve months of a Care Manager’s tenure. For example, at six months, the Care Manager is to have completed one Clinical Pathway episode with a 100% audit score.
The ongoing education of all clinical staff to maintain competencies, incorporate up-to-date evidence and ensure high quality care is equally important. To this end, FirstHealth provides deliberate required education that directly relates to chronic disease management and the Pathway standards of care. For example, there is an annual educational requirement in pharmacology in recognition of the rapid changes in pharmacology and the impact of medication regimens on patients.
Staff education is provided using a variety of approaches from a monthly electronic article of the month with a post test to on-site trainings on a specific targeted topic. The entire multidisciplinary team receives the same initial and ongoing training as it relates to chronic disease management.
Additionally, all clinical staff is trained in Integrated Care Management through Sutter Health. Training includes the key foundational principles of integrated care delivery including patient and family centered care, motivational interviewing, health coaching, health literacy as well as disease specific training.
Regardless of the discipline, every visit to the patient’s home is an opportunity to identify issues, reinforce education and deliver the care plan. To ensure all disciplines are consistent in what specifically is required to be reported, FirstHealth Clinical Guidelines were created to establish standardized parameters for vital signs and other health related measures or symptoms. So, for example, for diabetics, all visiting clinicians are to review and document the patient’s last recorded blood sugar. According to the Clinical Guidelines, any blood sugar reading that is greater than 250 is to be reported to the Care Manager. The Care Manager is then responsible for any follow up and for obtaining physician established parameters for patients who routinely fall outside the established Clinical Guidelines.
Pay for Performance
The long accepted standard of a productivity or visit-driven home health compensation plan has created a culture that focuses primarily on the number of billable visits completed in an eight hour work day as the marker of financial viability. A full-time nurse is justified based on the number of visits that must be completed – whether pay per visit, hourly or salaried, billable visits serve as the foundation of all home health compensation plans. Unfortunately, if the focus is on the billable visit, then the visit becomes the key metric by which administrators, managers and front-line nurses judge success, rather than the quality of care delivered.
The FirstHealth Pay for Performance Plan is designed to shift this focus from billable visits to an emphasis on quality of care. To this end, Care Managers are responsible for a defined number of patients. Visits are determined by patient need and the established standards of care. No financial incentive or compensation is offered for additional visits over a productivity goal. There is no productivity goal for RN Care Managers. Any extra pay beyond their salary is exclusively for delivering positive patient outcomes. Bonus dollars are paid to Care Mangers for achievement of quarterly clinical goals. Quarterly goals are established that are unique to the individual Care Manager and include: the hospitalization rate; emergency department utilization rate; one clinical outcomes measure; one process measure; and annually, the individual home health CAHPS (patient satisfaction) score are included. The transition from a visit driven compensation model to a performance driven payment model aligns the compensation plan with the core quality objectives of FirstHealth. It also gives the Care Managers more flexibility, autonomy and accountability for effectively managing their patients using all the tools and resources available. All other staff including clerical support staff is also paid quarterly bonuses based on organizational quality goals. Everyone in the organization has a critical role to play in the consistent delivery of high quality and effective care.
The FirstHealth Care Management Model is designed to deliver high quality, outcomes driven care that demonstrates consistent and measurable results. With the focus on helping the patient learn effective self management skills, the patient centered model, is an effective component of any population health strategy.
Trends and Projections in Hospital Stays for Adults with Multiple Chronic Conditions, 2003-2014
- Between 2003 and 2014, nonmaternal hospital stays among adults were two to three times more likely to involve multiple chronic conditions (MCC) than no MCC.
- The percentage of stays for adults with MCC increased from 63.5 percent in 2003 to a projected 78.1 percent in 2014, whereas adults without MCC decreased from 36.5 percent in 2003 to a projected 22.0 percent in 2014.
- The percentage of hospital stays for adults with MCC increased with patient age; the percentage was lowest among patients aged 18-44 years and highest among patients aged 65 years and older. However, the percentage of stays for adults with MCC increased most rapidly for those aged 18-44 years.
- Hospital stays for adults with MCC cost nearly 20 percent more on average than stays for adults without MCC. Average inflation-adjusted hospital costs for stays of adults with MCC increased from $12,000 in 2003 to a projected $14,500 in 2014, compared with an increase from $9,800 to $12,200 over this time period for stays without MCC.
- The average cost of stays for adults with MCC was about 20 to 25 percent higher among patients aged 45 years and older than among those aged 18-44 years.
Author: Patty Upham, RN, Director, FirstHealth Care Transitions