CMSA FOUNDATION–2020 CASE MANAGEMENT PRACTICE IMPROVEMENT AWARD RECIPIENT
Case manager Margo Gordon found herself in a Tennessee emergency room last year. It wasn’t the first time she had been there to help a member of a Medicaid health plan, operated by an affiliated plan of Anthem Inc., but she’s hopeful a new program will make it less frequent.
The member, whom Gordon had been working with for two months, had been diagnosed with schizophrenia and had suffered a psychotic breakdown. Gordon became aware the member was in the ER when she saw the member’s name on the list of patients admitted from the emergency department. Gordon’s health plan monitors the list for its High Outreach to Promote Engagement—or HOPE—a program created for the health plan’s most vulnerable populations to improve member outcomes and lower healthcare costs by anticipating and supporting member’s needs before and after they need medical help.
“I spoke with her to make sure she knows someone was looking after her,” Gordon said. “And she began to cry. No one knew where she was. She was very emotional about me being there with her.”
That connection isn’t developed in one meeting. Gordon visited with the member and her son for the first time in person at a homeless shelter a few months earlier and then later on the phone. Building a trusting relationship enabled Gordon to coordinate the member to receive care at a psychiatric and addiction inpatient treatment facility. She also played an integral role establishing power of attorney for the member’s mother.
“Going out and meeting with members opens up a different level of trust, and it establishes a relationship and the member can feel like they can trust you and that you are there for them,” Gordon said. “You become real to them and they can reach out to you. You are developing that relationship for when they need someone the most.”
Today, the member’s son is back living with her, and she has a positive relationship with her family. She is taking her medications on schedule and has a job. She also hasn’t been admitted to the hospital since the psychotic event in 2019.
From HOPE’s inception in 2018 until May 2020, Anthem-affiliated health plans had 3,533 members referred to the program, with a 69% engagement rate. This includes members in Anthem’s Medicaid, Federal Employee Program, employer-sponsored, individual, and Medicare health plans.
This work included interacting with 2,500 providers. As a result, emergency room visits and in-patient hospitalizations decreased on average by 50%. About 30 licensed clinicians provide this support. For this work, the HOPE program was recognized by the Case Management Society of America’s Foundation with the 2020 Case Management Practice Improvement award.
HOW DOES THE PROGRAM WORK?
Anthem created HOPE in 2018 to meet the needs of the most complex members—those with the highest rates of multiple chronic conditions and higher than average ER visits and inpatient admissions for both behavioral health and physical health.
HOPE’s case managers are licensed clinicians, serving as the central point of contact responsible for supporting all aspects of indicated services, regardless of diagnosis. This continuity of care strengthens the relationship between member and clinician. Members also work closely with other staff, who are certified peer support specialists and have personally experienced a mental illness or a substance use disorder.
“It all boils down to relationships,” said Kelley Pennington, Anthem staff vice president for behavioral health. “We are bombarded with communications, such as emails, texts, etc., that no one has time to read. We’re trying to develop one-on-one relationships—that can improve member’s health literacy and social determinants of health—with case managers and people who have walked a mile in their shoes.”
Case managers help members understand their healthcare, including how to take medication, and help them to follow up on appointments and their care. They may assist with providing transportation and accompanying them to their appointments. Case managers often assist members in finding community resources they may not have known about. However, this year COVID-19 has restricted how often case managers can be in the field. A process to meet with members virtually through videoconferencing has been established for those members who can take advantage of it.
Often, HOPE case managers bridge the gap for members as they are preparing for discharge from inpatient hospital care. Setting a medication schedule with discharge medications and at-home medications is crucial to avoid errors. Making follow-up appointments and how to contact their care provider are additional elements HOPE care managers take part in.
“They need to know they have someone who advocates for them and someone who will provide for them those resources they have not been able to connect with,” said Linsey Langmo, one of the managers of the HOPE program. “Often, they don’t know what’s available to them—either from insurance benefits or community resources. They need a supporter, and we can be that for them.”
The case manager’s first responsibility is to talk with the member, and that rarely happens by phone initially. Case managers are known to travel to unconventional locations to engage with clients. That might include outdoor living spaces for homeless patients or any shelter or other alternative living arrangements.
“Many members we work with don’t trust medical personnel or health insurance companies, but if you meet them at their door and say, ‘I’m here and I want to help you,’ it’s a whole different world,” said Langmo.