One of the most formidable barriers to improving post-acute care is lack of trust between patients and their care teams, says Jamie Philyaw, MSW, vice president of care management at Raleigh-based Community Care of North Carolina (CCNC), a nonprofit organization that has a contract with the state to manage Medicaid patients.
She remembers a 50-something-year-old patient met by one of CCNC’s care managers at the patient’s hospital bedside a few years ago. The care manager didn’t know it at first, but this patient was living in a tent—and lacked access to medications for his heart disease or to a cardiologist. The care manager spent many months building trust with this patient, who was repeatedly readmitted, and who was also struggling with substance abuse and behavioral health issues.
CCNC learned about this particular patient through a daily report on hospital admissions the nonprofit receives from facilities throughout the state. The patient’s repeated hospital visits led to CCNC’s team classifying him as a priority patient, which meant he needed immediate support. Because of the trust the care manager built with him, the patient agreed to a referral to a cardiologist and accepted the offer of secure housing through a local faith-based organization.
The care manager even facilitated delivery of the patient’s medications to his tent before he accepted housing. That was “the carrot,” Philyaw says. It demonstrated to the patient that his care manager was invested in him as a person and helping to improving his health.
In addition to daily reports on hospital visits across the state, CCNC also receives patient referrals from practicing clinicians and through embedded care managers at hospitals and practices throughout the state.
While some hospitals and physician practices receive a high volume of Medicaid patients and, thus, merit having a full-time CCNC care manager embedded at the facility, other facilities may have a care manager on-site a few hours a week. CCNC “meets patients where they are,” whether that’s at the bedside or in a physicians practice, or in their home (or tent, in the situation with the 50-something-year-old patient mentioned earlier), says Philyaw.
The organization provides services to all 100 counties in the state, which means it has “a lot of boots on the ground,” she says.
Physicians rely on the care managers to help determine patients’ complex needs and how to facilitate appropriate post-acute care, says Paul Mahoney, vice president for communications, CCNC. In fact, one care manager has relationships with physicians that span more than nine years, he says.
A critical aspect of what helps the program work is ensuring care managers are viewed as an asset by physicians. For example, CCNC’s care managers add value rather than cause disruption to a busy emergency room, says Philyaw. They often have office space and a regular schedule at the healthcare facility, which means patients have access to care management services when they need it. Care managers also provide detailed care management reports, attend follow-up visits along with patients, and, in some cases, document care in the EHR.
Post-acute care benefits
Care managers often meet patients before they’ve been discharged from the hospital—literally, while they’re still in a hospital bed. It’s at this point that a care manager can get involved in discharge planning—and schedule in-home assessments to determine any socioeconomic factors that may impact their approach.
An in-home assessment by CCNC was a lifesaver for an 8-year-old girl who was visiting the ER monthly due to severe distress from asthma, says Mahoney. The nonprofit got a referral from a physician who was alarmed about the number of times the patient had been to the emergency room, he adds. During the home visit, the care manager witnessed that the child’s home was infested with cockroaches and severe mold.