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Mount Sinai School of Medicine

A collaborative demonstration project focused on highly advanced care management brought together the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York City, for its expertise and training skills in palliative pain and symptom management; Franklin Health, Inc. (FHI) of Saddle River, New Jersey, for its industry-standard complex care management program; and Blue Cross/Blue Shield of South Carolina, which supplied patients with complex illnesses who could benefit from palliative care and care management.

FHI, one of the country’s leading disease management firms, has established the gold standard for the effective coordination and management of difficult, costly, high-utilization cases. Managed care organizations across the country contract with FHI to identify such patients from utilization data, provide on-site care coordination and work with health plan officials and primary care physicians to optimize coordination of care and prevent medical complications that lead to costly hospitalizations.

Mount Sinai School of Medicine, New York, New York, and Franklin Health, Inc., Upper Saddle River, New Jersey
Improving End-of-Life Care: Integrating Community Case Management and Palliative Care
Principal Investigators: Diane E. Meier, MD, and William Thar, MD, MPH
Focus: A partnership between an academic medical center and a private disease management firm to integrate patient-centered palliative care for community-dwelling adults with serious and life-threatening illnesses into an existing care management system through development of palliative care training and treatment protocols.

FHI, which bases its highly trained and closely supervised nurse care managers in the communities where the health plan’s members live, does not assume fiduciary responsibility for patient care or for coverage decisions. The care managers do not make treatment decisions for either the patient or the doctor. Instead, they provide information and recommendations, based on their established relationship with the patient, home-based assessment of the patient’s needs and ongoing monitoring of the patient’s condition. They are viewed as patient advocates, rather than as functionaries of the insurance company trying to save money. Yet this coordinating, educating and empowering service typically generates a return on investment averaging three or four to one for the insurer.

The Promoting Excellence grant project’s enhancement of this successful care management product involved a series of treatment protocols on pain and symptom management, advanced care planning and physician communication, accessible to the care managers via computer. It was supported by training in palliative care, symptom management, use of the protocols and communication skills for the care managers, taught by experts from Mount Sinai. Using these tools, the care managers were better able to identify patients’ needs for symptom management, end-of-life care and support, and then recommend action plans to their physicians.“The palliative care protocols are more specific than before,” says FHI’s director of research, Dr.William Thar. “Instead of saying to the doctor: ‘Can you do something about your patient’s pain?’ the care manager is able to say: ‘Here’s what the treatment guidelines would recommend to treat this patient’s pain.’” Thus, the palliative care protocols represent a refinement or a strengthening of a powerful and successful care management product, and a natural step in the ongoing improvement of an approach that FHI has effectively employed for a decade, he explains. It gives the nurses new tools and builds on an already existing and well-functioning system.

The company recently decided to roll out the palliative care protocols nationwide and to train all of its care managers from coast to coast in their use. “I think it’s very positive that a complex care management company of the quality and reputation of Franklin has adopted this program,” attesting to its success, notes Dr. Diane Meier of Mount Sinai School of Medicine, project co-principal investigator. The company’s preliminary data also shed light on other measurable results from the palliative care initiative, including:

  • Significant reduction in perceived burden of symptoms by seriously ill patients and improved symptom management scores eight weeks following admission in a number of key areas;
  • Increase in the number of advanced directives completed and used in clinical decision making;
  • Very high acceptance and patient satisfaction rates, as well as high acceptability rates from clinicians;
  • Increase in the number of identified domains of care that the nurse care manager identified as problems to be addressed; and
  • Increase in the number of new prescriptions ordered to treat specific symptoms (from 28 percent per patient in the control group to 64 percent in the palliative care intervention group).

“Patients in the intervention group received more prescription drugs aimed at symptomatic distress, including pain medications, which means the care manager has successfully contacted busy primary care doctors in their offices and, when indicated, gotten them to prescribe controlled substances,” Meier explains. “That’s incredible. The doctor still has to sign the order for the prescription, but I thought that would prove to be one of the biggest barriers to the project.”

The power of the palliative care intervention, she says, lies in empowering the nurse case managers not only to assess patients’ needs, but also to actually do something about what they find. “They were given the clear expectation that when a symptom was identified, they had to do something about it. Nurses do not want to be in the position of assessing things for which they are helpless to intervene—so they don’t do it,” Meier says. The palliative care protocols included very specific recommendations to share with the doctor, which was an important ingredient in the project’s success. FHI case managers trained in the protocols also report increased sense of empowerment and professional competence.

“Most hospitalizations occur in a crisis, when the whole care system falls apart and the patient ends up in the emergency room—the place of last resort and a highly inefficient setting to manage this patient population.”
- Dr. Diane E. Meier, Mount Sinai School Of Medicine

Return on Investment

FHI has worked long and hard on the challenge of identifying patients who really need this kind of intensive care coordination while being careful not to enroll too many patients whose care needs and complexities are not as severe. The company tracks overall cost savings generated by its complex care management program—as well as the extremely high rates of acceptance, patient satisfaction, likelihood to recommend the program to others and positive contributions to quality of life. All are at an 80 percent level or above.

Although the palliative care protocols have clearly enhanced the company’s product, the company’s leaders emphasize that FHI was already in the palliative care business. “I would say that our complex care management program is an intensive example of palliative care,” says FHI’s medical director, Dr. Jeff Gruen. “Look at what our nurses do. The majority of their time has to do with supporting patients, not about a specific treatment but about assessing their social support system, improving their knowledge, making sure they have a safe environment and can identify their providers and coordinators of services. We also advocate for patients when they need flexibility in extra-contractual benefits and we usually have a formal mechanism for submitting such recommendations,” Gruen asserts.

In recent data from a partnering insurance plan, FHI calculated a return on investment of 3.2 ($2.7 million in savings on $0.8 million in care management costs—or $22,000 per managed case) for the second year after implementing complex care management. The company posted an even higher return on investment of 4.3—equating to $5.4 million in savings on $1.3 million in costs or $33,000 per managed case—in the third year of implementation. These positive impacts on costs principally result from reductions in average numbers of hospital inpatient days, admissions and readmissions per claimant.

This is where the potential for cost savings resides, Meier notes. “Most hospitalizations occur in a crisis, when the whole care system falls apart and the patient ends up in the emergency room—the place of last resort and a highly inefficient setting to manage this patient population. The hospital avoidance occurs not because somebody says, ‘You can’t go because we won’t pay for it,’ but because the need is averted— which is also good for the patient.” When patients feel safe at home because they know they have a care coordinator who knows them and can help them at a moment’s notice, they are much less likely to take their problems to the emergency room. “It’s the ones who don’t feel safe at home, who feel abandoned, who end up in the hospital,” she notes.

For FHI’s complex care management in South Carolina, bolstered by the palliative care protocols, “it probably does save money, although our actuaries sometimes roll their eyes when they hear claims of cost avoidance,” says Dr. Ashby Jordan, medical director of Blue Cross/Blue Shield of South Carolina. “We view it primarily as an empowering process, and our experience is that patients really do like it. I’m convinced that patients go to the emergency room less often, based on the activities I hear the nurses doing. Our senior management is pleased enough that the program would be worth doing even if it only broke even,” he relates.

“We are a mutual company—not a for-profit—but we are exquisitely market driven,” Jordan says. “This product is not a hard sell in this market.” He adds that the medical system typically does not do a very good job of educating patients with complex care needs about their medical condition and treatment options. “A relatively simple, straightforward intervention can make a huge difference in giving people what they want in their final days. And people do make difficult decisions once they have the information.”

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.

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