Social Case Management at the Bedside Outreach Program

Social Case Management at the Bedside Outreach Program With Newark Beth Israel Medical Center

How can an organization serve the traditionally underserved, publicly insured population, when it is often difficult to contact this group for outreach and education about disease management? Faced with the dilemma of delivering health care and communicating to these members, Horizon NJ Health developed an innovative program that seeks to meet these challenges with strategic solutions in order to provide access to services.

Called the Social Case Management at the Bedside Outreach Program, this initiative was designed to identify and develop outreach programs for the top 20 percent of high-risk members in the Supplemental Security Income (SSI) group, Pediatrics/High-Risk Obstetrics, and other special needs categories, who use a hospital as a medical home. Given that these members are admitted to the hospital, the best place to reach them is in the hospital, at the bedside. Meeting with the members one on one offers the opportunity to use intervention and assessment skills for on-site Horizon NJ Health Social Case Management staff.

One of the key components in the program called for the development of a working partnership with a hospital, which experienced a high volume of admissions from the targeted population. In March 2001, the Social Case Management at the Bedside Outreach Program began at Newark Beth Israel Medical Center, a 671-bed teaching hospital affiliated with Saint Barnabas Health Care System in New Jersey.

"We evaluated how we could best serve these members, and it seemed logical to reach them in the hospital, one on one," noted Pam Persichilli, RNC, Director of Utilization Management at Horizon NJ Health. "The program works for many reasons, but it is important to stress that Horizon NJ Health's Social Case Manager is there only to help the patient. The primary responsibility involves meeting the members, conducting timely intervention, and specifically discussing options and/or using the opportunity to handle questions about each member's plan benefits. Horizon NJ Health is there to promote medical follow-up after discharge, and provide education on the managed care process, while offering help to coordinate access to preventive and community services. The program seeks to increase PCP, specialist, ancillary, and community links and services for improved outcomes.

"From the beginning of the project, we established guidelines, so that the Social Case Management at the Bedside Outreach Program could work effectively to ensure patient satisfaction," explained Pam Persichilli. "It was important that Horizon NJ Health and Newark Beth Israel Medical Center function autonomously, yet coordinate services on the patient's behalf without compromising patient confidentiality or duplicating services and efforts. The Social Case Management at the Bedside Outreach Program was developed as a working, joint partnership based upon cooperation. As partners, Newark Beth Israel Medical Center and Horizon NJ Health were determined to guarantee patient care and maintain patient satisfaction.

"Newark Beth Israel has been a phenomenal partner," Pam Persichilli added. "We appreciate their cooperation in helping us achieve the services these patients deserve. This has been a successful collaboration. Thanks to Newark Beth Israel, we were offered office space, including the use of a telephone and other administrative resources and tools, so we were able to concentrate on patient concerns," noted Pam Persichilli.

Tita Visitacion RN Director of Case Management at Newark Beth Israel Medical Center, praised the program and said, "What is most important is that we ensure patient satisfaction while we maintain the continuum of care. This program seems to successfully achieve that objective, since both partners work to coordinate the services our two organizations offer, without duplicating services or infringing on patient privacy. Horizon NJ Health staff has been accepted in its distinctive role, and the program benefits everyone."

"It was important that the personnel, those social workers and nurses on staff at Newark Beth Israel, were comfortable with the project," stated Irma Alicea, MSW, LCSW, Manager of Social Case Management at Horizon NJ Health. Our purpose there was not to intrude, but only enhance the mission for patient satisfaction. Patient confidentiality is critical, and we wanted to make it clear that it was not our intent to interfere with the responsibilities or job functions of the Newark Beth Israel caseworkers or other hospital staff."

Presently, one Horizon NJ Health Social Case Manager is assigned to the project on-site in Newark Beth Israel. Using lap-top computers, the Social Case Manager can remotely access the Horizon NJ Health member database and review a member's information before the case management visit, without any need to review the patient's medical charts.

"We try to link members to Horizon NJ Health's Disease Management Programs," stated Irma Alicea. As a part of the assessment and visit, the Social Case Manager might discuss how Horizon NJ Health programs could help improve or maintain health and wellness. "We review each case to see if the member is eligible for any other programs that they are not currently utilizing, such as SSI, disability, or community programs. While we schedule home visits as needed, this intervention system has proven very successful."

Irma Alicea observed, "The relationship built during the visit and the assessment of a member's needs facilitates the process of reducing hospital admissions and improving access to care. In some instances, we might learn of a family's problem and try to help by reporting or referring the problem to the appropriate state division, with the goal of the member receiving additional services."

"Follow-up care is a critical component for the program's effectiveness," Pam Persichilli remarked. "The Horizon NJ Health staff coordinates all activities with the Newark Beth Israel staff. Both organizations consider the patient's well-being, confidentiality and comfort. This program demonstrates that there is no duplication of effort, only teamwork on behalf of the patient. Newark Beth Israel has been a valuable partner. The program was designed so that all parties could be comfortable with the separate, but equally critical, roles each handles, which only serves the patients. Patient contact has been positive, and the outreach has effectively offered patients as much information as they require.

"An analysis of the program data shows that after Social Case Management encounters and member meetings, the number of hospital readmits has decreased nearly 15 percent," commented Pam Persichilli. "Correspondingly, as we expected, the number of member visits to PCPs and the use of home health aides and transportation services has increased. Through Social Case Management encounters at the bedside, these members are obtaining expanded access to the community services and increasing their options for follow-up care. Since members have discovered resources for their care, they no longer rely primarily on the hospital as their only recourse."

Newark Beth Israel has requested that Horizon NJ Health consider expanding the Social Case Management at the Bedside Outreach Program to another high-use facility. The program has proven successful in its goal of informing members about resources available for their care and opening a new path to member outreach, education, and access to care, thereby decreasing hospital inpatient visits.