In the complicated world of today’s healthcare landscape, it can be more difficult than ever for O&P patients to navigate the logistical world of coordinated appointments and documentation to ensure they receive the care they need and reimbursement for their care is processed correctly. That’s where traditional case managers come in to fill an important gap in the process. Case managers say that working with them is a win for everyone involved: Patients are happier because they receive better service and their care on all fronts is being taken care of, and O&P practices earn loyal patients and someone to help patients with insurance claims. Even practices that do not have an in-office case manager often find that working with a case manager from a third-party source, or finding other creative ways to help patients through the healthcare maze, such as adopting the patient navigator model pioneered by Harold P. Freeman, MD, in 1990 to eliminate barriers to timely cancer care, benefits both patients and practices alike.
“If the patients have someone watching the system to make sure the process goes much more smoothly, they will get to the end of their medical ordeal much faster than if they are floating on their own,” says Susan Gordinier, a medical case manager for PACBLU, headquartered in Honolulu, Hawaii.
More Need Than Ever Before
As insurance claims and coordination of care become increasingly difficult, the need for case managers or other professionals to assist in coordinating care is growing, experts say.
“Even when I think I have everything coordinated down to having transportation lined up, something still happens,” Gordinier says. “Mistakes are happening at a greater rate than ever before.”
There’s always something that pops up and threatens to slow down necessary care, she says. For instance, most insurance companies now require a pharmacy review before a patient can get a prescription. If the person in charge of the review is on vacation or doesn’t answer the phone, the patient can’t get the prescription quickly. It’s Gordinier’s job to make the necessary calls to somehow push the review through and get the prescription for the patient.
“I call these glitches, and they happen constantly,” she says. Patients with amputations are well suited for work with case managers, experts say. The patients have to deal with their complicated medical problems at the same time they have the initial psychological toll of learning to live with their amputations.
“You are talking about someone who has had a loss,” says Lauren Danahy, RN, BS, MBA, CCM, LNCC, principal at Willamette Nurse Consultant Group, headquartered in Portland, Oregon. “Even the most prepared patients, [and] even if they had counseling ahead of time, nothing can really prepare them for the actual event. The impact is a grieving process, and it’s a privilege for me to be able to be there for them and help them through that.”
Case managers’ work doesn’t just stop at medical care, they say. It’s their job to help the patient with whatever he or she needs to get better.
For instance, working with a patient who lost half of his foot in a workplace accident went well beyond medical care for Mary Shelley, RN, CDMS, COHN-S, an Oregon nurse employed by Stubbe & Associates, headquartered in Minnetonka, Minnesota.
Along with coordinating the patient’s care and finding providers, Shelley arranged to have his home modified so he could get around easier, signed up a laundry service so he wouldn’t have to haul his laundry up and down steps, and found a temporary home health aide to help prepare his meals and clean his house while he worked to recover.
“A person who has been injured needs to be able to get back to the activities of daily living,” she says. “It takes time, and I help them with that.”
A Unique Approach to Patient Care Coordination in O&P
It is the importance of connecting patients with all the resources they need to be healthy and coordinating with various channels to ensure optimum care across the rehabilitation spectrum that, according to Eileen Levis, HCA, president of Orthologix, headquartered in Trevose, Pennsylvania, led the practice to launch a patient navigation program in June based on the Harold P. Freeman, MD, model widely used in cancer centers. Implemented as a two-year pilot program that was rolled out for Orthologix’s prosthetic patients, it has received positive feedback. Orthologix chose this model because in researching cancer patient navigation programs, the data was overwhelming regarding the success of such programs, Levis says, and since there weren’t O&P patient navigator programs, the company felt it was something that should be done.
While distinct from case managers, patient navigators are another way to approach a patient-centric model of care that bridges the entire spectrum of the individual’s needs. As Levis explains, “Our patient navigators help to guide patients through treatment. When needed, they assist in gathering medical records. They work with the patient so that they understand their insurance benefits and policies. They help with accessing specialists and scheduling appointments.” But their role extends beyond assisting with strictly medical issues to help patients overcome barriers that might interfere with their ability to access resources necessary for their recovery. “They connect patients with financial aid, transportation, or child care when needed. They make sure the patient and/or caregiver understand the personalized plan of care. They keep track of treatment progress…,” Levis adds.
However, in contrast to the type of counseling Danahy can provide as a medical professional during the adjustment or grieving process that someone with a recent amputation may go through, Levis clarifies that, “our patient navigators are nonclinical workers and as such cannot provide medical or psychological advice. But they do provide emotional support, and by utilizing a needs assessment tool, they often discover the patient’s need for specialized services.”
Working With Case Managers
With few case managers located in O&P practices, most case managers that O&P practitioners work with represent insurance companies, workers’ compensation agencies, or hospitals, and they will come to appointments with patients to help make sure their care is on track and going smoothly. Even in those cases, the case manager can be helpful to the practitioner as well as the patient, experts say.
“When it’s a high-cost item like a prosthesis, the costs are going to be scrutinized much more carefully,” Gordinier says. “The process to get it approved can go much faster if a case manager is involved.”
Also, these case managers are aware of the full spectrum of care the patient is receiving and can give important information to prosthetists that might not otherwise have been communicated, she says.
Levis says that patient navigators can work closely with case managers as part of the team in these situations as well by sharing information that is critical to getting the patient through the rehabilitation continuum.
Certified or Not
The case management industry has an ongoing debate about professional certification. While certification is generally not required by law, more employers are requiring their case managers to be certified or have the ability to be certified upon employment, according to the Commission for Case Manager Certification.
According to the commission, case managers have to put in a certain number of hours before earning certification and are tested about their knowledge of designing and monitoring a care plan, coordinating care with physicians and other providers, and evaluating patient progress and tracking outcomes.
Some of the experts we spoke with mentioned that trained nurses, who later gain certification, are well suited for the job because of their experience in the medical world.
“If you are looking at any job postings anymore, companies don’t want someone who isn’t certified or able to be certified,” Danahy says.
There is currently no national standard for patient navigator certification according to the Harold P. Freeman Institute, however, proper training is still important, and several organizations are taking the lead to provide comprehensive training. The patient navigators for Orthologix’s program completed their training through the University of Colorado, School of Public Health, Patient Navigation Training Collaborative.
Better Coordination, Better Care
In the case of the patient navigator program, Levis says, “We have had an astonishing response from patients, insurers, physicians, and rehabilitation specialists. Our program incorporates matching some patients with like peers. For new amputees, especially, this has proven to be an immense help during the transition time…. What we may consider a small intervention is so important and appreciated by our patients.”
Shelley says that the job of case managers is to help keep care on track so the patient can get back to his or her lifestyle as quickly as possible. Oftentimes making this happen can be complex and confusing, and it’s why she has a job. “We don’t get the easy cases,” she says. “If they were easy, they wouldn’t need us.”
So far, Orthologix’s patient navigator program has proven successful in helping with complex cases as well and is quickly building a reputation. “The insurers we are working with through the navigation program are very excited to have their patients able to take advantage of this resource,” Levis says. “Our physicians and therapists are amazed at the depth of the program, and as such, we are consulted on some very difficult cases.”
Perhaps it is because of the difficulty of coordinating all the pieces of care that, in the end, Shelley says most of the patients she works with are grateful for the work she’s done. “Even if they weren’t receptive to me in the beginning, more often than not, when it’s time to say goodbye and I reach out my hand, they pull me in for a hug and thank me,” she says. “You really get to know these people, and they rely on you. We are their cheerleaders and their coaches.”
Overall, it’s the team focusing on the patient that makes the difference in better care, according to Levis. “Case managers, patient navigators, physicians, physical and occupational therapists, orthotists, and prosthetists are all vitally important people in the lives of our patients,” she says. “I believe it is all of our responsibility to adopt care models and best practices that treat patients as whole people and not merely the sum of their parts.”
Maria St. Louis-Sanchez can be reached at .
