Case Management

1. Case Management In a Primary Care Setting

2. Team Members • Susan Wickey, RN • Daiva Gestautas, RN • Nancy Flynn, RN • Dr. Paul O’Keefe • Dr. Matt Fitz • Provider Relations Department • ATC Attendings, Residents and Medical Students

3. Background Information • Access to Care is a public/private partnership program making primary health care services available to those individuals who are not eligible for public health insurance programs and or private insurance. • Loyola, Dr. Paul O’Keefe, Dr. Matt Fitz along with a team of attending physicians, and over 15 Residents and Medical Students support a primary care clinic. • Clinic located at an off site location. • Clinic sessions two half days per week. • Ancillary staffing no longer available to provide support services as of October 2007. • Patients have limited access to their Primary Care Physician. • Limited resources available to assist with phone calls and medication refills. • No clinical charts available as a resource for staff to access. • Medication lapses due to difficulty in contacting physicians for medication refills. • Emergency Department accessed for non-acute illnesses.

4. Project Aim Statement: To establish a Primary Care Case Management model for the Access to Care patients and physicians to ensure appropriate utilization and improve quality of care while reducing health care costs. Magnet Forces of Magnetism –Force 7

5. Improve access to primary care physicians. Provide access to appointment scheduling Provide access to clinical staff if needed. Advocate for services needed. Impact appropriate utilization of services. To provide outreach to patients who presented to the ED along with follow up and review of discharge instructions. Goals of the Primary Care Case Management Model

6. Solutions Implemented: • Physician meeting with Provider Relations to review protocols. • Provider Relations staff available to take calls Monday –Friday 7:30 AM-5:00 PM. • Nursing Triage and Intervention as needed. • Outreach was performed to patients who presented to the ED. Follow up appointments were scheduled and a review of discharge instructions took place. • Nursing Staff were available to the physicians to assist with individual patient needs. • Ability to overbook clinics to avoid unnecessary ED visits.

7. Solutions Implemented: • Scheduling of appointments as appropriate. • Transition to electronic medical records. • Referrals to specialists and services were authorized based on Milliman Care Evidenced Based Guidelines. • Medication refills were processed with the physicians intervention.

8. Phone calls were logged on a daily basis. Clinical staff were available to talk with the patients and assists with requests. Identification of patients who presented to the ED. Medication refills to the pharmacy were reviewed and authorized if approved by the PCP. Referral request were reviewed and authorized according to guidelines and PCP approval. Referrals to specialists and services were authorized based on Milliman Care Guidelines. Tracking:

9. Phone Volume: • Access to Care Phone Volume 1-08 through 12-08

10. Measuring Success: Facility ChargesCase Management Initiated January 21, 2008