case management magazine south central june/july

Past Executive Director of DFW Case Management

Making Her Mark in Her Career

BK Kizziar

Best Practices in Post Acute Transitions with Reliant Home Health

25 Headhunter’s Tips

Case Management in Practice with Century Hospice

Living WeLL: Key Pilates Benefits

integrating Case Management and Palliative Care

Patient navigator

Page 41

Feel Better. live Well.

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Case Management Magazine Ad.indd 1 1/20/12 4:00 PM

c a s e m a n a g e m e n t c o n n e c t o r . c o m | 1

23BK KIZZIARone simple idea behind her passion and education.

South/Central

Contributing EditorsBK Kizziar, R.N., B.C., CCM

Mathew L. Feller, VIce President of Sales & Marketing with Century Hospice

Judy Wilson, R.N.., B.S.N., EVP of Business Development with Reliant Home Health

Mark Jaffe

Tara Mc Kerman

Journal of Palliative Medicine

Advertising 817-821-9935

Production 817-232-3344

For more information on Case Management Magazine please email: [email protected]

Copyright © Case Management Magazine, LLC, all rights reserved. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission from Case Management Magazine, LLC. Printed in the USA.

contents

depARtments 2 Focus on CM

6 Home Health Business with Reliant Home Health

9 Business Development

16 Legislation | HC News

20 Living Well

26 Professional Development

feAtuRes13 Regaining Mobility for Patients

with Prosthetics Science

19 Case Management in Practice with Century Hospice

26 Integrating Case Management and Palliative Care

In eveRy Issue43 Patient Navigator Patient navigator is a color coded

referral guide to provide to patients upon discharge from hospitals.

48 Rubic Legend of level of care facilities

provide patients to meet their need for better recovery, and reduce the re-admit rate.

2 | c a s e m a n a g e m e n t c o n n e c t o r . c o m

Every product on the market has a brand—a tag line that defines the concept of the product. Usually an easy to remember phrase that when heard conjures up a mental picture of the product and maybe even pleasant memories of experiences that included the product. Recall the product that used this branding? “______; For Those Who Think Young.” How about this one for those who live in the Metroplex? “If You’re Not Shopping With Me, You’re Burning Money.” Even actors are branded. How about, “Make My Day,” or “I’ll Be Back,”?Healthcare is no exception. Hospitals have been branding for years. Using tag lines to project the message that their services are superior and their staff the most caring. Managed care companies have also identified the importance of branding themselves and their products. Most recently, nursing has begun to move into a position of branding their services. Johnson & Johnson has sponsored a number of television commercials and print ads featuring nurses at the bedside. They depict the care and sensitivity that is associated with nursing.

It has often been said that case management is the best kept secret in healthcare. We go about our business of saving the day without fanfare or the expectation of praise. It is what we do, who we are. We affect the lives of those of whom we serve and ask for nothing in return. And all too often the clients we serve don’t even realize the impact we’ve had on their lives. Many are unaware that they have even received case management services and wouldn’t be able to recall the name of their case manager if asked. And we continue to do what we do, anonymous and unrecognized. Always marching to the mantra, “Patient Advocate.”

The most current phrase that healthcare professionals are using in their own organizations to define their purpose is “Patient Centric.” By definition, healthcare centers on the recipient of the services provided. Every area of healthcare can accurately say that they are “Patient Centric.” The revival of this focus is likely the product of the black eye that healthcare in general has endured over the last few years. The press related to the big bad managed care companies denying life giving care; hospitals more focused on heads in the beds than the individuals who occupy those beds; physicians vying for business and running patients through their offices like an assembly line. Then there is the matter of healthcare reform. What a mess that has turned out to be and is still undetermined. So it makes sense that healthcare payors and providers see the need to develop a “kinder, gentler” persona. What better way than to focus on the reason they exist: the patient. So it is that every area of healthcare and every healthcare specialty can

the Branding of case Management

A VoICE FoR PATIENTS

focus on cM


say they are patient centric. It’s like returning to the basics of their purpose. Patient Centric has become the brand of most healthcare professions.

So does case management jump on the Patient Centric bandwagon and become just one more healthcare profession announcing their focus to be Patient Centric? Patient Centric is really a generic term. If all of healthcare is using it as their brand, it really becomes a broad

definition of many things while specifically defining little. But case management is definitely Patient Centric, is it not? Our steadfast role as patient advocate certainly makes the practice of case management Patient Centric. And regardless if we are employed in hospital, payor, workers comp or any other are of case management, we focus all of our efforts around ensuring the best outcome for our clients. That further makes

us Patient Centric. However, to adopt a brand that has become a generic phrase for all of healthcare does not do our profession justice.

What is it about the practice of case management that makes our version of Patient Centric different? How do we set ourselves apart from the multitude of other healthcare professions who are Patient Centric? When considering this question we are forced to


also consider the fact that case management is practiced in a multitude of settings under a multitude of titles by a multitude of clinical backgrounds. At the recent national CMSA conference it was noted that there are currently 26 recognized titles for the practice of case management. Case Manager, Care Coordinator, Patient Navigator, Clinical Resource Manager, Care Manager are only a few. Then there are all the settings for practicing case management: every area of healthcare provider, managed care, Medicaid, Medicare, Medicare Replacement, Worker Comp, disability, independent and so on. After that, the various clinical areas represented in case management are nursing, social work, speech/physical/occupational therapists, pharmacists and more.

What do all these titles and all these practice settings and all these clinical areas share in common? They are all Patient Centric. Okay, let’s build on that to discover what about case management stands above the Patient Centric label. All areas of practice want good outcomes. All work to ensure the client receives the most appropriate level of care. All must be good stewards of the payor fund. All must give the client the information required for them to make informed healthcare decisions. All are activists in obtaining services

for the client. All are held to the Case Management Standards of Practice. What is the one word that best describes what case managers in every area practice do? ADVOCATE.

By definition an advocate is one who argues or pleads for a causes. Synonyms for advocate include promote, advance, cultivate, encourage, foster and hearten. Pretty much the definition of case management, isn’t it? Taking for granted that case management, along with all of healthcare, is Patient Centric, and what further defines case management above that generic label is the way in which we Advocate for our clients by promoting quality healthcare services, advancing the practice of case management through education and certification, cultivating positive relationships among our healthcare peers to ensure the most appropriate services, encouraging our clients to become engaged and informed decision makers, fostering the best utilization of the payor

fund while obtaining necessary services and heartening those new case managers to success by mentoring and encouragement. Our clients reap the benefit from each of these endeavors. And by involving the client in their own healthcare they become better equipped to manage their own health needs. So while other healthcare professions perform services on the client, case managers provide services in partnership with the client.

That pretty much says it. So as we realize the importance of branding and examine how best to brand case management, keep in mind that case management is anything but generic. We can embrace healthcare’s general tag line of Patient Centric. But what sets us apart and makes us the voice of our clients is our mantel of Advocacy: Case Management, The Patient’s Voice in Healthcare.

[email protected]

“It has often been said that case management is the best kept secret in healthcare. We go about our business of saving the day without fanfare or the expectation of praise. It is what we do, who we are. We affect the lives of those of whom we serve and ask for nothing in return.”


Transitional care is defined by the American Geriatrics Society as a ”set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.” Everybody looses when there is poor coordination and poor communication from the inpatient setting to the outpatient setting; yet everyone can win when great transitions are executed with Caring, Concern, Kindness and Compassion.

Caring, Concern, Kindness and Compassion are common characteristics of health care professionals. Home Health delivers these same commonly held beliefs after the hospital stay and into the patient’s home. The Reliant Home Health team is passionate about delivering a best in class “care experience” with the goal of improving the health and welfare of patients, their families and caregivers.

Before The Hand Off:Hospital stays can be a confusing

and stressful time for patients and their families, but the qualities of caring, concern, kindness and compassion can mitigate this stress. Patient and family perceptions begin with the first patient and family contact and continues throughout the continuum of care. Patient and family members feel less anxiety when they know what to expect from all providers.

During The Hand Off:At Reliant Home Health,

discharges from a facility are accomplished with an in-hospital evaluation by a clinician or trained liaison to manage the patient transition. The experienced transition professional identifies several key areas to assure a smooth transition including: The patient is appropriate for

home health care services Patients know what to expect

from home health services Patient demographics Primary and Secondary

diagnoses Confirming the ordering

physician Confirming the primary care

physician Inquiring as to other health

problems and what caused the hospital stay

Current medication reconciliation list

Socioeconomic concerns

HoMe HealtH Business

By Judy Wilson, R.N., B.S.N., EVP of Business Development with Reliant Home Health

BEST PRACTICES IN PoST ACUTE TRANSITIoNSBefOre, During AnD AfTer “THe HAnD Off”Best Practices While never Losing Site of Truly Caring for the Patient


By Judy Wilson, R.N., B.S.N., EVP of Business Development with Reliant Home Health

Transportation challenges Psycho-social and

Environmental factors Equipment needs

These key areas effecting a patient’s transition are captured in a “High Risk” assessment to determine which patients should be “Flagged” for the delivery of specific protocols of care. All high -risk patients are flagged in the agency point of care technology, which sets in motion the specific teaching and care protocols to meet that specific patient’s needs. The ultimate

goal is to provide the right care, in the right place at the right time in a caring and effective manner.

The importance of Communications:

Standardized and accurate communication between the hospital case managers and the home health provider is critical to prevent care gaps and to ensure the home health agency team members have all the information necessary to be successful in meeting the patient’s needs. Patients with

terminal diseases, multiple chronic medical conditions, mental health conditions, fragile support systems, issues with housing, issues with transportation, inability to obtain prescribed medications and poor compliance patterns need to be managed at a higher level of care.

The Patient & family As the Centerpiece of Care:

Safe, effective and efficient care includes the home health agency team partnering with patients and caregivers to achieve


successful outcomes and to prevent re-hospitalizations. The Department of Health and Human Services is committed to promoting high quality health care and improving patient outcomes. One example is the Affordable Care Act, which calls for the progressive reduction in Medicare payments to hospitals for patients readmitted within 30 days of discharge. With the focus on reducing preventable hospitalizations, the family and caregivers are an integral part of the health care team. According to Eric A. Coleman, MD, greater engagement of patients and their family represents the centerpiece of any attempt to improve the quality of transitional care. We all should be elevating the status of family caregivers as essential members of the care team. Often these are the individuals we rely on to execute the plan of care and serve as de facto care coordinators. For this reason patients and their families need to be recognized as full-fledged members of the interdisciplinary team.

Working Together – it Takes a Care Team:

Case Managers who work across multi-disciplinary teams in the acute care setting reach across disciplines as they handoff information to providers, share insight, form partnerships, identify resources and solve problems. The engagement of all participants in the patient’s care means we all have common ground to work together to ensure a safe and successful discharge. Key elements for the success of any interdisciplinary health care team are transparency, effective communication that defines problem solving criteria. builds collaboration and accountability.

The Magic of Caring:Executing an effective

transition hand-off requires all team members to have clear roles and responsibilities. But when a patient successfully moves out of the hospital setting to their home setting and thrives we can all celebrate a successful hand off. And the real magic happens when all the pieces of the transition hand-off are delivered with true Caring, Concern, Kindness and Compassion.

Eric A Coleman, MD, MPH 2011, based on article What Will It Take to Ensure high Quality Transitional CareProject Red Training Program http://www.ahrq.gov/qual/projectred

Judy Wilson, R.N., B.S.N., is Executive Vice President of Business Development of Reliant Home Health. Reliant Home Health was name “2011 Best Home Healthcare Agencies To Do Business With” by Case Management Magazine. For additional information, please call (972) 390-7733 or visit Reliant Home Health’s website at www.relianthomehealth.com.

“Standardized and accurate communication between the hospital case managers and the home health provider is critical to prevent care gaps and

to ensure the home health agency team members have all the information necessary to be successful in meeting

the patient’s needs.”


Business developMent

Finding your an keep you calm, focused and most importantly, get you hired!

1. Don’t Become Prey on the Job HuntIf someone offers to craft you a ‘killer résumé,’ put you in touch with the ‘hidden job market,’ or coach you to become a newer, more-marketable you, just say ‘No.’ Whether they’re asking for $3,000 or $300, it’s overpriced.

2. Just Relax...SeriouslyOn the job hunt, remember that it’s not you …it’s the

economy. Stay calm. Hyperventilating is never pretty, especially during an interview. Prospective employers want Jason Bourne, not Jason Alexander.

3. Rise in the Wee HoursEvery successful person since the advent of opposable thumbs has risen at the crack of dawn. Set your alarm and get moving.

4. Make Your Résumé Just the Facts, Ma’amWrite your résumé the way Jack Webb spoke on Dragnet: simple, direct statements in government-style, gray-

1 0 | c a s e m a n a g e m e n t c o n n e c t o r . c o m

flannel prose. The number of pages doesn’t matter; substance does. Tell your story and get out of there.

5. Keep Cover Letters ShortThink haiku. Didn’t you hear the whole world has ADD? Since attention spans max out at about three seconds, mention that your résumé is attached and say goodbye

6. Automate Résumé-PostingUse services such as resumerabbit.com and jobdrone.com that post your résumé to multiple job sites at once. They can save you hours of data entry.

7. Get a Recruiter’s Attention the old-Fashioned WayDo memorable work in your industry or profession and we will find you, despite your employer’s best efforts to conceal your brilliance from the rest of the world.

8. Don’t EditorializeWhile preparing a résumé or interviewing, resist the urge to tell me you’re a ‘highly motivated, results-driven, visionary, world-class entrepreneur.’ May I decide that for myself after I’ve had time to consider your many accomplishments?

9. Think Before Posting Your Photo on LinkedInIf it’s a solid asset, great, then use it. Please make sure we can see your face clearly, the mug shot was

professionally done, and it conveys a ‘strictly business’ demeanor. When in doubt, leave it out.

10. Be Yourself on InterviewsForget the prepared material. Someone who has difficulty talking ‘off-script’ about non-business topics never seems completely natural or unrehearsed.

11. Come Clean ConstructivelyDon’t be freaked out by the interview question: ‘What wrong turns or unfortunate choices have you made in your career?’ Ability to answer this confidently demonstrates your capacity for honest self-analysis and introspection.

12. Let Major Job Sites Work for YouUse job-search agents such as theladders.com or execunet.com, where you sign up and receive job listings by e-mail. You’ll access more jobs, more recruiters, and more opportunities.

13. Stay in the LoopContact former professors with whom you had particularly good bonds. Odds are they can advise you on how to get current in a changing job market.

14. Don’t overtax ContactsWork your contacts, but don’t work them over. Your network is a precious resource and should be treated as such. Now is the time

to use it … but gently. Ask for a reference, not a job. When you don’t put your friends on the spot, they’re more inclined to help you.

15. Take Community ActionLook for a community service project sponsored by the employer you’re interested in and offer your skills to it. You will learn about the company culture and make some key contacts.

16. Keep It Rosy During Job InterviewsMaintain a positive, upbeat attitude. Everyone wants to be around a winner. Never criticize your current or former manager or employer.

17. Make Them Feel ImportantPlease remember that headhunters, like lecherous old men, need a little love, too. (Occasionally it’s an overlapping demographic.) When a recruiter calls, say the magic words: ‘Hold on a second. I have to close my door.’

18. Talk About the TeamWhether interviewing or happily employed, learn to communicate without using the words ‘I’ and ‘me.’ Talk about the players and the total effort, acknowledging and crediting others. It will become contagious and you’ll get your share of the glory, too.

19. Don’t Get Ahead of YourselfOne small negative step can sink

a job search. Never ask about telecommuting, job-sharing, whether or not relocation is necessary, what sort of car will be part of the package, or whether this is a cubicle or windowed-office position.

20. Never Be a Toady in the Presence of a GiantThe key to dealing with larger-than-life people who rule your destiny is this: Never suck up, but remember the conversation is always about their issues, not yours.

21. Avoid the ‘Department of Redundancy Department’Keep track of your career networking efforts so you never send out duplicate e-mails or notes, as this will be perceived as disorganization—or worse, sloppiness.

22. Remember It’s Not over Till It’s overWrite a follow-up note when you don’t get the job. This is so unusual that you’ll stand out. Perhaps the interviewer will know of other opportunities and recommend you. Don’t be afraid to ask that question in the note.

23. Win Via DiscretionAssume that people never keep anything you tell them in

confidence. Gain mastery over this secret weapon and you will become powerful beyond your wildest dreams.

24. Don’t Accept Second PlaceIf you were runner-up for a position that was exactly in your sweet spot, you have nothing to lose by calling the hiring manager 90 days later and asking how that new hotshot is working out. You may be surprised to learn that she wishes she had gone with you after all. Stranger things have happened.

25. Know That You Will Get a JobUnderstand that despite what you see on the cable networks, we are not living in the End of Days. Yes, it’s miserable out there, but it will be a bad memory sooner than you or CNBC imagines.

Mark Jaffe and Tara McKernan


Cutting EdgE tEChnology You deserve a prosthesis that will help you live your normal life. Our prosthetists are dedicated to helping you achieve that by using the most appropriate and latest technology in components and socket designs.

PErsonal touCh Every patient is unique. Our prosthetists are dedicated to working with each patient to design a quality prosthesis specifically to help that patient meet his/her goals and dreams. Our prosthetists listen to your desires and concerns and work with you to help you get back to living your life. Have a problem with your device? Our prosthetists are always just a phone call (210.949.0488) away to answer questions and make adjustments.

Quality FabriCationAll of our fabrication is done in house by our skilled technicians. This allows us to bring you a quality prosthetic device quickly. We believe you should not have to wait for weeks to get back to living your life.

PatiEnts FirstAt Prosthetic Science San Antonio we pride ourselves in putting our patients first. Contact us to learn more about how we can help your patients.

Serving All of San Antonioprostheticscience.com | 210.949.0488 | 4242 Medical Drive | San Antonio, TX 78229

Allow Your Patient to Live the BeST QuALiTY of Life ToDAY

We go to great strides to ensure our patients get the most appropriate and latest technology available for their specific prosthetic needs.

ProSTheTic Science SAn AnTonio

c a s e m a n a g e m e n t c o n n e c t o r . c o m | 1 3

EVERY PATIENT IS UNIqUE. our prosthetists are dedicated to working with each patient to design a quality prosthesis specifically to help that patient meet his/her goals and dreams. our prosthetists listen to patients desires and concerns to help you get them back to living their life. –Prosthetic Science San Antonio

Prosthetics provide MAny BenefiTS fOr A PATienT after the amputation of a limb. One of the greatest benefits is MOBiLiTy, and being able to live inDePenDenTLy. Technological advances in prosthetics now allow patients to perform recreational activities, including swimming, hiking and skiing. Meet companies making a difference for Texans, by giving them Life WiTH fuLL rAnge.


Prosthetic Science San Antonio is now offering amputees the world’s first and only commercially available complete bionic leg – the SYMBIONIC Leg from Össur, a global orthopedic company with more than 40 years of experience in prosthetic innovations.

The new SYMBIONIC Leg is the newest addition to Össur’s line of Bionic Technologies, a series of “smart” prostheses that feature artificial intelligence (AI) and wireless communications systems, highly sensitive internal sensors, and advanced biomechanical designs. Prosthetic Science San Antonio is one of the first prosthetics practices to offer this technology in the United States.

The new SYMBIONIC leg’s artificial intelligence technology acts like the ‘brain’ of the device and functions similarly to the body’s central nervous system, by processing information about changes that occur inside and outside the limb as if the limb were still intact. The bionic technology also helps the leg automatically adapt to individual walking styles and

different environments, continuously learning and improving its response over time.

The SYMBIONIC leg leverages the proven functionality and capabilities of two of Össur’s popular bionic prosthetic breakthroughs – the RHEO KNEE® and PROPRIO FOOT® – into a single, fully integrated unit, with seamless interaction and unprecedented functionality for above-the-knee amputees. The leg actually facilitates everyday movements, unlike traditional prosthetic legs that are passive and stable. A traditional prosthetic leg doesn’t actually take a step for the person; normally it is dragged along when the person takes a step, hindering them from walking up stairs or hills. As a result, amputees wearing traditional prosthetic legs tend to rely more on their sound leg to compensate for their amputated leg, and instinctively will not use their prosthetic leg effectively. In contrast, the bionic leg allows the amputee to bear weight and function more as if it were a real leg, while the powered bionic foot actively flexes so the person is actually taking steps and walking more naturally.

For aMPUteeS WitH BioniC teCHnoLogY FroM ÖSSUr

PRoSTHETIC SCIENCE EXPANDS MoBILITY oPTIoNS


A new study in Germany found that microprocessor knees such as Össur’s RHEO KNEE facilitate walking on stairs and slopes with fewer problems, because it can adapt to different walking speeds. The SYMBIONIC Leg is capable of intelligent terrain adaptation, creating stability on a variety of walking surfaces, including grass, ramps and uneven ground. As a result, amputees have reported feeling more confident while walking; they are able to maneuver more naturally without as much concern of tripping or falling, going out of their way to avoid obstacles, or needing to focus solely on the act of walking.

The SYMBIONIC Leg also has been shown to reduce an amputee’s asymmetric movement and gait deviations – physical adaptations typically made to

compensate for their prosthesis. If these are allowed to continue over an extended period of time without correction, they may contribute to pain, fatigue, over-use or even injury to an amputee’s sound limbs.

With Össur’s SYMBIONIC Leg adapting to individual walking styles and different environments, amputees can walk with greater confidence and freedom. And Össur’s technology positions Dallas Prosthetics as a leader in bionic technology.

Prosthetic Science San Antonio accepts most insurances and Medicare. Please call our office today: 210-949-0488

“ The new SYMBIONIC leg’s artificial intelligence technology acts like the ‘brain’ of the device and functions similarly to the body’s central nervous system, by processing information about changes that occur inside and outside the limb as if the limb were still intact.”


legislation Hc news

[Condition of Participation rule (CoP); placing a medical staff member(s); physicians on governing board of hospitals.]

PoWER oN oR oFFStumped! CMS Revisiting the CoP Rule:

CMS has motioned to implement physicians to be a part of the governed board members of Hospitals.


CMS has reported to

have ‘overstepped’

their boundaries again

in the free enterprise

in the land of the

healthcare. Hospitals

take pride within

their governed board;

keeping doors’ closed

during board member

meetings to have a

nonpartisan voice in

the role of patient

care.

July may very well be one of the hottest month’s during the calendar year, though for Centers for Medical & Medicaid Services (CMS) the issue between Hospitals, Physicians, Board Members, and Investors sets an all time record high.

According to American Hospital Association (AHA), and several provider groups, CMS included a requirement in the May final rule, although it was not in the October 2011 proposed rule. After much heat, CMS stated they well reconsider the Condition of Participation Rule (CoP Rule).

The (AHA) rejected the ruling causing much resistance between Hospitals’ governed board members, investors, and CMS. AHA stated, “Having a medical staff member on the governed board may limit boards and investor owned hospitals. ”In many states, including Texas rule against Hospital organizations to elect physicians as governed board members. American Medical Association (AMA) supports CMS due to the large number of the aging, allowing new medical team members to understand the board members and growing hospitals’ medical staff. The AMA sides with CMS, stating it will enhance the growth in the medical staff, and provide a level of development. “While the corporate executives, attorney, civic leaders, and other non-clinician(s) who sit on the governing body often bring relevant expertise to the overall management of the hospital,

as non-clinicians, they are not equipped to evaluate and guide patient care at the facility," said James Madara, Executive Vice President with AMA.

CMS officials say they acknowledged both sides. "We're aware of the concerns around this rule and are taking them seriously," CMS spokesman Brian Cook said. Cook added, "We are looking at how to avoid any unnecessary conflicts for facilities, while also allowing medical staff's perspective on quality of care to be heard by an organization's governing board."

Because of the number of comments and revisions, CMS has agreed to revisit the CoP Rule, though CMS will likely not publish guidance in time for the July deadline--the date the final regulations are supposed to go into effect, according to the CMS memorandum.

“ We are looking at how to avoid any unnecessary conflicts for facilities, while also allowing medical staff's perspective on quality of care to be heard by an organization's governing board.”


HC_CaseMangMag1.pdf 1 1/4/12 12:41 PM


How one dies is as important as how one lives. When the inevitable arrives, the need for emotional support, physical comfort and attention to religious and spiritual practices can quickly overwhelm any need for medicine or curative treatments. Hospice care provides for these needs and keeps terminal patients close to their families in familiar surroundings.

A Concept of Care Hospice is a unique concept of

care, originally based on the notion of offering a place of shelter and rest, or hospitality, to sick and fatigued travelers. According to the National Cancer Society archives, Dame Cicely Saunders at St. Christopher's Hospice in London first applied the term "hospice" to specialized care for dying patients in 1967. Today, hospice provides compassionate care for those suffering from incurable diseases, allowing them to live peacefully and comfortably.

right Time One key to the success of hospice

care is early involvement. Identifying early on that hospice is the right choice for a family can make a dramatic difference in the quality of life for the patient and a comfortable closure for the family.

Many physicians and other health care professionals have an appreciation of the fact that hospice care enables family and loved ones to participate in the experience and to get help from hospice care in managing their own

feelings and reactions to the illness. Today, these same professionals are increasingly supportive of the early identification for hospice eligibility so that patients and their families don't delay their decision to take advantage of the fullness of the benefit.

right Place Hospice care is provided to patients

where they reside. Although frequently hospice is provided in a patient's or a family member's home, it also is offered in nursing homes, assisted living centers and other long-term care facilities.

The remedy for Many While hospice care may not be for

everyone, it offers a plan of care to fit the needs and meet the wishes of many patients and families facing terminal illness.

Since living and dying can be equally important, hospice must be considered a viable option for the many faced with the devastation of death. As a fully reimbursable benefit under Medicare, Medicaid and most private insurance

plans, there are an increasing number of people recognizing the benefits of hospice care.

Although still in embryonic stages in terms of awareness, it is the job of every hospice organization, physician, medical professional and family member familiar with this benefit to share their experiences and help educate the American population. This will spread the word about the best way to cope with terminal illness and its associated grief and perhaps make someone else's pain and suffering a bit more bearable.

Hospice is not about death, but rather about quality of life. It's about the many ways in which experts spanning the medical community can seamlessly meet the wishes of patients, family and friends to ensure comfort and closure as life nears its end.

Matthew L. Feller serves as Vice President of Sales & Marketing for New Century Hospice. For More Information Contact your local New Century Hospice team or visit our website at: www.newcenturyhospice.com

CASe MAnAgeMenT in PrACTiCe

HospIce cARe


ivcenter.com

“An Innovative solution to your everyday outpatient IV needs”Innovative Infusions, LLC has two centers in Central Texas (San Antonio and Austin) and provides high quality infusion services in a well controlled environment with a Provider on-site.

In this environment, our patients are part of a health care team focused on infusion and injectable therapy and striving for quality and cost containment. Some of the ServiceS offered:Infusion and injectable therapyIndividualized care of the patient’s IV devicesPICC line maintenance (placement coordination)Experienced nurses (RN’s and NP’s) certified in IV therapyInsurance verification and local reimbursement servicesExtended hours for BID antibiotic deliveryClinical monitoring and support

PatientS Lead a normaL LifeStyLeOutpatient Infusion therapy offers patients the availability of continuing medical treatments in the outpatient setting while resuming their everyday life activities. We offer flexible scheduling and weekend appointments.

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oPen 365 dayS a yearA comfortable place to relax and receive your iv treatment.

Accepting medicare and most private insurances, our facilities are patient-focused and able to administer IV therapy 365 days a year.

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512.261.4800


Living with Rheumatoid Arthritis (RA) means living with increasing pain and discomfort over a long period of time with no available cure. RA is a chronic disease that has been the subject of extensive study by researchers worldwide, and many questions still remain unanswered concerning the condition. While there is no absolute cure for the disease, there are treatment options available to alleviate symptoms. Innovative Infusions, with two outpatient infusion centers located in Arlington and North Richland Hills, offers both a treatment plan and medication options to help manage RA symptoms for anyone who suffers from the disease.

RA causes daily aches, swelling, discomfort, and loss of function in the joints. It occurs when the immune system begins attacking healthy tissue, specifically the synovium, a thin membrane that lines the joints. Fluid builds up in the joints and inflammation occurs, causing excruciating pain and

immobilization in the joints. Some may experience only periods of pain followed by long periods of remission, while others deal with RA symptoms on a daily basis. Those who suffer from RA can be both physically and emotionally debilitated by the effects of the disease on their bodies. At this time it is not clear whether the cause of RA is due to genetic or environmental factors. Although the disease does not discriminate against age, gender, environmental factors, or genetics, it typically develops between ages 30 and 50. Of the 1.3 million people who suffer from RA in the United States, 70 percent are women. Women are more likely to suffer from severe symptoms and experience less remission than men, although they may receive similar treatments, according to a study in Arthiritis Research& Therapy titled “Women, men, and rheumatoid arthritis: analyses of disease activity, disease characteristics, and treatments in the QUEST-RA Study.”

Nevertheless, Innovative Infusions is well-equipped with the latest RA treatments to accommodate both men and women. Registered nurses and nurse practitioners are available 365 days a year in both outpatient offices to help prescribed patients find comfortable relief paired with high-quality service. In addition, several of the most recent and most effective IV infusion medications to date are available at Innovative Infusions to treat RA, including Remicade, Orencia, Rituxan, and Actemra.

Typically these IV therapies for RA include pre-medications such as Tylenol, steroids, or antihistamines to

reduce post-infusion reactions. These are the more common drugs used in conjunction with RA treatments, yet some doctors will not initially prescribe pre-medication for a variety of different reasons. Fortunately, the skilled nurses on staff at Innovative Infusions are trained to detect the signs of an infusion reaction. If the patient begins to experience a reaction that can possibly be alleviated by pre-medication, the nurse who is providing the infusion will contact the patient’s physician to get a prescription.

RA infusion therapy can take anywhere from 30 minutes to 2 hours depending on the medication prescribed and dosage administered. Nurses on staff are well-versed on the IV infusion treatment; they will review the medication with the patient, and walk them through the infusion process so patients are aware of what is happening before and during the treatment.

Innovative Infusions provides a relaxing environment for infusion patients. Facilities are furnished with flat screen TVs, Wi-Fi connection, blankets, and comfortable recliners for the patient’s well-being. Patients are welcome to bring their own laptops to work or surf the Internet as they wait. They may also bring snacks to eat during the infusion process, books to read, and music to listen to through their headphones. Some patients will bring their own pillow to sleep. Meanwhile, Innovative Infusions nurses and nurse practitioners will make every effort to ensure that the patient is comfortable and well looked-after during their IV infusion.

rHeUMatoid artHritiS

treatMent oPtionS

Reduce symptoms


living well

Key pilates Benefits for senior fitness exercise Pilates can slow down the signs of aging by

making your joints and muscles more pliable thus making every day movements easier.

It is a gentle type of exercise that leaves your body feeling relaxed but also provides the full body workout that other traditional workouts do..

The deep breathing that accompanies Pilates exercise can oxygenate your blood and leave you feeling exhilarated after a workout.

Pilates assists in continuing your fitness goals when you’re at an age when your body is not capable of doing what it used to do.

It increases joint movement, overall mobility and bone density which is especially important as you age.

Pilates decreases stress and tension, joint inflammation, swelling and stiffness to provide a better quality of life for you.

Pilates Benefits Baby Boomers to Stay

Young & HealtHYPilates benefits are winning the hearts and minds of thousands of baby boomers all over the world as they take part in slower, gentler forms of exercise like Pilates. As we age, other forms of exercise like jogging or traditional workouts are no longer an option because of the stress it puts on joints. Pilates exercises are the perfect solution for baby boomers because it provides a full body workout without the wear and tear.

Basic Pilates includes stretching, lengthening for better posture and resistance training. You are working your body in a gentler way but getting the same results and in many ways the results are better.

Let’s step back in time to a place where Jane Fonda ruled the roost. Bounce, dance, high kick and over stretch yourself into fitness. And remember…feel the burn! No pain no gain!

Now jump ahead thirty years to present day. Those loyal aerobic class takers are aging and are a part of the fastest growing group in the USA, Baby Boomers. But now, they can’t jump up high, stretch down low, or run around the bases like they used to. They are aging.

Although men’s health and fitness has always revolved around more active activities such as sports and running, Pilates benefits has everything a male baby boomer needs to stay in shape and even increases their level of fitness with less stress and risk to the body.

For female Baby Boomers, maintaining flexibility and strength as they age is important. Pilates is so gentle on the joints, Pilates benefits really lends itself well to an aging population.


Born in Chickasha, Oklahoma, the only child of working parents who always instilled the importance of character and faith, BK Kizziar was a tomboy who would rather be out playing “Rawhide” with the horses and cattle while her mother was standing at the door calling for her to come in and practice the piano. The horses and cattle won and she attended a “rodeo college” in eastern Oklahoma (Boomer Sooner all the way) where she majored in nursing.

BK came to Texas in 1979, she had pretty much taken root with the exception of one Saturday every fall known as “OU-Texas Weekend.” She married a Texas-boy who had never lived outside

Tarrant County. They live in Southlake with a sweetie-pie yellow lab named Brie who pretty much rules the roost, where she has taken on a hobby, designing and creating stained glass art.

Today, BK Kizziar is making her mark in her career as the role of the Past Executive Director of the DFW chapter of CMSA; CMSA stands for Case Management Society of America. “Case managers are probably the best-kept secret in healthcare. We haven’t done enough, especially among the consumers of healthcare, to let them know what case management is, what it can offer them as consumers, and some of the really positive ways they can benefit from case managers and what we do. So, that’s one

thing our organization strives to do. Typically, we’re made up of nurses and social workers. If anyone is interested in learning more, the national organization has a web site, www.cmsa.org, and our chapter has a web site, www.dfwcmsa.com. these sites offer opportunities to learn more, plus these conferences provide opportunities to get more of an overview of many different areas. As you were suggesting, we’ve got managed care, hospital, workers compensation, independent case managers, rehab, and really, in every area of healthcare, you find case managers.” says BK.

Before BK’s journey in fulfilling her passion, she completed her clinical background in nursing. The majority of her clinical

BK KIZZIARONE SIMPLE IDEa BEHIND HER PaSSION & EDuCaTION


nursing was in the emergency Room. In the mid 1980’s when case management was primarily known only in the worker’s compensation arena she was offered an opportunity to become a Discharge Planner in an acute rehabilitation hospital, Dallas Rehab Institute. A new administrative team at DRI introduced a case management modle, replacing the discharge planning modle. It was during that time that a dynamic mentor became the driving force behind BK’s transition into a case manager. “Laura Luck, now Laura Martinez, instilled in me a passion for case management and became my mentor,” says BK. BK continues, “Upon leaving DRI I joined Laura in her independent practice, my primary case load consisted of worker’s comp and liability clients.”

Later, BK became the manager of case management at Blue Cross Blue Shield of Texas. “Working on the payer side of healthcare I learned that being a good steward of the available healthcare dollar is one of the highest forms of patient advocacy. It also became apparent that most individuals do not understand their employer benefit plan, and I recognized the need for benefit literacy in order for individuals to become their own healthcare advocates,” says BK.

Upon leaving BCBSTX, BK embarked on the need of education for case management. Combining her experience

she gained in the workforce, she created BK & Associates. BK & Associates provides approved continuing educational presentations to case managers and other healthcare professionals, prep course for taking the national certification exam for case management, and working with hospitals all over the country to assist them in developing programs to ensure exceptional transition of care services with positive outcomes and lastly, to provide information to the healthcare consumer that will allow them to become informed advocates for their own healthcare and that of their families. BK & Associates also works with hospitals to evaluate their current case management program, recommendations for improvements that will lead to successful transitions in care while also improving the utilization of the healthcare dollar. “Recommendations are important part of the evaluation,” says BK. “These recommendations may include anything from additional case management education and mentoring to a total restructuring of the program including onsite management until project completion. Collaborating with advocacy groups, we offer informational presentations to healthcare consumers about a variety of subjects including personal healthcare advocacy, how to talk to healthcare providers and understanding healthcare benefits.” BK &

Associates has been striving to meet these objectives for the last ten years.

BK told Case Management Magazine, that she had been fortunate to have made many contacts during her career in case management prior to going into private practice. “Many hours of thought and prayer went into the decision to leave a salaried position with an established organization that offered a great benefit package. The stark reality is that in private practice there are no paid holidays or vacations, no regular hours, no healthcare benefits and no retirement package. Whatever I end up with when I close the practice is going to be whatever I put into it. All of these things must be considered and planned for prior to taking that giant step. Make sure when the step is taken there

“The experience with my Mother only

further ignited my passion to educate the

healthcare consumer about how to access

services, how to learn their benefit coverage

and how to ask questions about the

care they receive.”


is solid ground underfoot and not quicksand.”

The biggest challenge BK has ever faced as a daughter, nurse and case manager came when her mother was diagnosed with a glioma (malignant brain tumor) in 2007. Although totally independent, living alone and still driving in little Chickasha, at ninety-one years of age she made the decision not to seek treatment. Her only request was that she be able to stay in her home. With the support of her husband and case management peers BK turned over the business to others and went to stay her Mother. The seven months that followed were the most wonderful and the worst BK had ever experienced. During that time she watched her mother and best friend bravely face her last days. “I was her sole caregiver and I saw in her the quiet strength of character that she possessed during her life, an embodiment of courage, unbowed by suffering. When she fell asleep for the last time in death I knew it was only to awaken in the radiance of grace where she was met by Daddy who had preceded her some 25 years earlier,” says BK.

“One of the terrible lessons learned from that experience was that the quality of healthcare one might expect to receive is directly related to where they live. Services taken for granted in the Metroplex are not available in all rural areas. The quality and expertise of providers vary even in large cities, consumers

unaware of how the system works can become casualties of the same system they depend on for their care. Misunderstanding of healthcare benefits, especially Medicare and Medicare Replacement policies can leave patients and families with unexpected bills. Mother had a ready-made nurse to meet her care needs and a case manager to ensure continuity of services and appropriate expenditure of her healthcare benefits. However, most people don’t have that built in consultant to manage their care.”

BK’s career as a case manager has been a part of the national professional organization Case Management Society of America (CMSA). As a charter member of the Dallas-Forth Worth Chapter of CMSA she has seen the organization grow to become one of the largest chapters in the United States. She has served as the Executive Director of the DFW CMSA Chapter for six years. She assumes the responsibility of the treasury, all of the business aspects of the chapter, such as negotiating and signing contracts, all of the banking,…and more. “I take care of all the coordination as a non-profit, both at the state and national level, the chapter budget, all of the financial affairs involved; it’s kinda’ like being a business manager.” BK remains an active participant in the national organization currently acting as co-chair for the national CMSA Education Committee.

The Dallas-Fort Worth chapter

was chartered in 1991. This is their 20th Annual Conference. The chapter meets monthly, September through May, with summers off. Over the entire year, they have several educational conferences. The largest conference is held in the spring, the “Annual Educational Conference.” The chapter also has a 2-day fall seminar, with a little different focus, and on a smaller scale. The Strategic Planning Committee within the chapter host “Taking It On The Road” seminars, where they take one and two-day seminars to other areas in North Texas, but away from DFW, to foster networking with case managers in those places, and provide them with some continuing education they don’t otherwise have.

BK Kizziar, an empowering woman has made her mark in her career, family life and volunteering by one simple idea behind her passion, education.


JOURNAL�OF�PALLIATIVE�MEDICINEVolume�7,�Number�1,�2004©�Education�Development�Center,�Inc.

Integrating�Case�Management�and�Palliative�Care

DIANE�E.�MEIER,�M.D.,1 WILLIAM�THAR,�M.D.,2 ASHBY�JORDAN,�M.D.,3

SUZANNE�L.�GOLDHIRSCH,�M.A.,1 ALBERT�SIU,�M.D.,1 and�R.�SEAN�MORRISON,�M.D.1

ABSTRACT

Most�seriously�ill�Americans�live�at�home�under�the�care�of�their�primary�physician�and�with�thesupport�of�family�caregivers.�To�reduce�costs�while�simultaneously�improving�the�quality�of�pa-tient�care,�insurers�have�increasingly�turned�to�the�concept�of�case�management.�While�case�man-agement�is�targeted�to�individuals�with�life-threatening�illnesses,�palliative�care�assessment�andinterventions�are� typically�not� included�in�the�management�protocols.�An�academic/care�man-agement/health�plan�partnership�between�Mount�Sinai�School�of�Medicine,�Franklin�Health,�acare�management�organization,�and�South�Carolina�Blue�Cross�Blue�Shield,�was�formed�in�1998to�test�the�utility�of�integration�of�case�management�with�formal�palliative�care�assessment,�feed-back�and�recommendations�to�treating�physicians,�and�ongoing�support�for�implementation�of�apalliative�care�plan.�The�goal�of�the�project�was�to�ensure�identification�and�optimal�care�of�seri-ously� ill� patients’� complex� needs,�while� facilitating� doctor-patient� continuity,� improving� pa-tient/family/physician�communication,�providing�assistance�with�decision-making,�ensuring�qual-ity�care�at�home,�and�promoting�efficient�use�of�health�care�resources.�Care�management�nurseswere�randomly�assigned�to�a�control�(usual�care)�group�or� to� the�intervention�(palliative�care)group.�Intervention�nurses�were�trained�in�formal�palliative�care�assessment�and�interventions,supported�by�treatment�protocols�and�communication�strategies�with�treating�physicians.�Mea-surements�included�symptom�burden,�prescribing�practices,�advance�care�planning�status,�satis-faction,�and�health�care�utilization.�These�results�are�pending�completion�of�study�run-out�andanalysis.�Preliminary�programmatic�results�indicate�that�combining�palliative�care�with�the�casemanagement�approach�is�a�logical,�feasible,�and�effective�strategy�to�improve�the�care�of�seriouslyill�patients�living�in�the�community.�Franklin�Health�has�offered�the�program�to�their�entire�clientbase�because�they�feel�that�the�integration�of�palliative�care�into�their�case�management�programimproved�the�standard�of�patient�care.�Blue�Cross�Blue�Shield�of�South�Carolina�has�also�chosento�sustain�this�enhanced�model�of�care�management�for�seriously�ill�patients.

119

INTRODUCTION

WHILE MORE THAN 50%� of�Americans� die� inhospitals,� this� statistic�masks�the�fact�that

the�overwhelming� majority�of�terminally� ill� pa-

tients�spend�most�of�their�last�year�of�life�at�homebeing�cared�for�by�their�families�without�the�as-sistance�of�formal�home�care�services.1 This�smallgroup�of�complex�and�seriously� ill�patients� (ap-proximately�1%�of�the�commercially�insured�pop-

1Hertzberg�Palliative�Care�Institute;�Department�of�Geriatrics�and�Adult�Development,�and�Mount�Sinai�School�ofMedicine,�New�York,�New�York.

2Franklin�Health,�Inc.�10�Mountainview�Road,�Upper�Saddle�River,�New�Jersey.3Blue�Cross�Blue�Shield�of�South�Carolina,�Columbia,�South�Carolina.

Promoting�Excellence�inEnd-of-Life�Care


ulation�and�5%�of�Medicare-covered�lives)�drivesone�third�to�more�than�one�half�of�all�health�careexpenditures� because� of� high� hospitalizationrates�and�costly�treatment� needs� (Fig.� 1).2 In�aneffort�to�not�only�improve�care�but�also�to�mini-mize� spiraling� health� care� costs,� insurers� haveturned�to�case�management�as�a�key�componentin�the�care�of�seriously�ill�patients�with�complexneeds�(Fig.�2).�In�one�study�of�18�large�Medicarehealth� management� organizations� (HMOs),� vir-tually�all�included�case�management�programs�ofvarying� degrees� of� intensity,� which� conductedscreening,�assessment,�care�planning,�implemen-tation,�and�ongoing�monitoring.3 Although�casemanagement�programs�are�often�directed�at�pa-tients� with� serious� and� life-threatening� illness,they�typically� focus�primarily�on�service�coordi-nation,� to�a� lesser� extent�on�medical� evaluationand�decision�making,�and�only�rarely�incorporatestandard� palliative� care� assessment� and� inter-ventions� in� their� role� and� functions.4–9 Con-versely,� whereas� palliative� care� assessment� andfeedback�to�physicians�has�been�shown�to�be�both

feasible�and�to�improve�outcomes�in�settings�suchas�hospice,�the�hospital,�and�in�long-term�care�set-tings,10–15,17–21 such�assessment� rarely� occurs�incommunity�settings�where�most�seriously�ill�per-sons�live.

Why�are�persons�with�serious� illness� in�needof� community-based� palliative� care� serviceswhen� hospice� care� is� widely� available� in� theUnited� States?� At� present,� only� approximately20%� of�all� adult� decedents� in� the� United� Statesare�served�by�hospice.11,19 The�median�length�ofstay� in� hospice� has� steadily� declined� in� recentyears� to�a�median�of�25�days11 and�one�third�ofhospice�patients� receive� services� for� less� than� aweek�before�death.�Many�patients�and�families�inneed�of�palliative� care� fail� to�access�hospice�be-cause�of�regulatory�restrictions�requiring�a�prog-nosis�of�6�months�or�less�and�patient�agreementto�give�up�insurance�coverage�for�disease-modi-fying� treatments� in�order� to�be� eligible� for�hos-pice�benefits.18,22,23 As�a�result,�for�the�77%�of�per-sons� who� die� of� chronic� illnesses� other� thancancer,�and�for�those�with�serious�illness�of�any

MEIER�ET�AL.120

FIG.�1. Care�management�focuses�on�the�needs�of�patients.

Worried�wellSelf-resolving�illnessLow�grade�acute�illness

��

��

70

60

50

100

90

80

40

30

20

10

Low

Cost�perClaimant

Complex�Patients

Patient�TypeManagement

Approach

DemandManagement

DiseaseManagement

CaseManagement

Complex�CareManagement

%Claimants

Multiple�co-morbidities

Often�terminal

Several�providers�of�care

Psychological/social/financialupheaval

High

Significant�diagnosis

Chronic�diseasesModerate�to�severe�acute�illness

Medium


kind�whose�prognosis�is�uncertain,�or�who�wishcontinued� access� to� life-prolonging� treatments,the�current�hospice�benefit�model�is�a�poor�fit.�Forthese�reasons,�alternate�models�of�palliative�caredelivery�are�needed�for�a�large�proportion�of�com-munity-dwelling� persons� with� serious,� chronic,and�complex�illness.

In�1998,�an�academic/case�management/healthplan� partnership� was� formed� between� MountSinai�School�of�Medicine;�Franklin�Health,�Inc.,�acase�management�organization� serving�complexand�high�cost�patients;�and�South�Carolina�BlueCross� Blue� Shield,� an� insurance� company� con-tracting�with�Franklin�for�case�management�ser-vices.�Funding�was�obtained�from�Promoting�Ex-cellence� in� End-of-Life� Care� National� ProgramOffice�of�The�Robert�Wood�Johnson�Foundationto� design,� pilot,� and� evaluate� a� new� model� ofhealth� care� delivery� with� goals� involving� inte-gration� of� routine� complex� case� managementwith�formal�palliative� care�assessment,�feedbackto� treating� physicians,� and� support� for� imple-mentation�of�treatment.

Because�community-based�complex�case�man-agement� is� a� rapidly� growing� and� increasinglyavailable�means�of�delivering�care�to�a�vulnerableclass�of�patients�with�costly�healthcare�needs,�thiscollaborative� academic/industry� initiative� to

study� the� effectiveness� of� delivering� palliativecare�through�case�management�programs�has�thepotential�for�broad�generalizability.�The�true�mea-sure� of� the� feasibility� and� effectiveness� of� thismodel�of�will� be�whether�the�study�interventiondelivers� improved� patient� care� without� signifi-cantly�increasing�utilization�and�costs.�The�claimsdata�required�to�evaluate�these�outcomes�are�notavailable� at� this�time�and�will� be�published�at�alater� date.� This� report,� therefore,� focuses�on� theinitial�study�design�and�methods,�implementationof�the� intervention,� barriers� encountered,� subse-quent�modifications�in�the�study�design,�and�theresponse�of�the� case�management� company�andthe�purchasing�insurer�to�the�project.

PATIENT�POPULATION�AND�SETTING

Patients�targeted�by�this�project�were�seriouslyill,�commercially�insured�HMO�members�who�en-tered�into�a�complex�case�management�programthrough�Blue�Cross�Blue�Shield�of�South�Carolinaindemnity� plans� and� their� affiliate� HMO,�Com-panion� Health� Care.� Patients� were� screened� byFranklin�Health�and�identified�as�appropriate�forcase�management�through�a�proprietary�method.Criteria� for� entry� into� the� Complex� Care� Man-

CASE�MANAGEMENT�AND�PALLIATIVE�CARE 121

FIG.�2. Matching�resources�to�needs.

NEEDSCM/DM�=�case�management/disease�managementCCM�=�complex�case�management

Demand�Management CM/DM

Res

ourc

es

CCM-palliative�care


agement�Program�include�specific�diagnostic�cat-egories�(cancer,�heart�disease,�chronic�lung,�kid-ney,� liver� disease,� major� trauma,� degenerativeneurologic�disease)�and�resource�utilization�datasuch�as�hospitalization�or�home-care�service�useindicative�of�complexity�and�service�needs.

Blue�Cross�Blue�Shield�of�South�Carolina,�head-quartered�in�Columbia,�South�Carolina,�has�morethan�1�million�members�in�South�Carolina�alone.Through� government� contracts� and� additionalbusiness,� the� company� serves� an� additional� 21million� customers�nationwide,� making� it�one�ofthe� largest� Blue� Cross�Blue� Shield� programs� inthe�United�States.�Its�leadership�has�made�a�firmcommitment� to� offering� complex� case� manage-ment�services�to�their�members�in�South�Carolina,and�was�willing�to�serve�as�a�test�site�for�the�pal-liative�care�intervention.

Franklin� Health,� Inc.� is� a� for-profit� nationalcommunity-based�complex�case�management�or-ganization,�with�offices�located�in�Upper�SaddleRiver,�New�Jersey�(,www.franklinhealth.com.).With�a� large�and�successful�program�of�patient-centered,�complex�case�management�for�the�high-risk� seriously� ill� patient� in� a�managed� care� set-ting,� Franklin’s� patient� base� extends� to� all� 50states.� A� computerized� information� system� en-ables�detailed�tracking�of�outcomes�both�for�bothindividual� patients� and� groups.� In� addition� toSouth�Carolina�Blue�Cross�Blue�Shield,�Franklinhas�multiple�corporate�clients�including�managedcare�plans,�health�systems,�and�large�self-insuredcorporations.

Franklin� Health� provides� an� intensive� andhighly�standardized�system�of�complex�case�man-agement�delivered�to�patients�and�their�familiesprimarily� in�the�home,�but�which�remains�in�ef-fect� regardless�of�patient�venue.�Approximately25%–30%�of�Franklin’s�patient�population�dies�oris�referred�to�hospice�while� receiving�case�man-agement.�Most�of�the�remaining�patients�are�dis-charged�when�their�medical�condition�stabilizes,or�resolves.�Average�length�of�case�managementservices� is� 5� months.� The� Complex� Care� Man-agement�Team�(Fig.�3)�includes�a�centrally�located(in� Upper� Saddle� River,� New� Jersey)� physiciancase� manager� employed� by� Franklin,� who� pro-vides�medical�direction�for�team�nurses�and�com-municates�with�the�treating�physician;�a�centrallylocated�(also�in�Upper�Saddle�River,�New�Jersey)nurse�clinical�account�manager�who�is�responsi-ble�for�case�selection,�supervision�and�support�ofnurse�care�coordinators,�and�coordination�of�the

team� and� team� conferences;� and� typically� four�local�community-based�nurse�care�coordinators,who� provide� local� community-based� coordina-tion�of�services�and�direct�(initially�in-person�andsubsequently� telephonic)� support�and�advice� topatients�and�their�families.

Because� the� care� coordinator� nurses� are� geo-graphically� based,� they�are� able� to� identify� andimplement�community�supports�for�each�patientand�family�unit.�Weekly�(or�more�frequent)�teammeetings�are�held�by�telephone�and�review�of�in-dividual� cases� occurs� throughout� the� course� ofcare.�Day-to-day�communication�occurs�both�bytelephone� and� through� electronic� informationsystems.� The� goal� of� the� care� provided� by� thecomplex�care�management� team�is�to�try�to�im-prove�the�likelihood�that�the�patient�will�receivehigh-quality�and�cost-effective�care�in�accordancewith�his�or�her�informed�wishes.�Franklin’s�lead-ership� considers�the�highly� structured�and�con-sistent�management� framework�to�be�the�key�toits� success:� individualized� high-quality� patient-level�services�are�provided�in�a�uniform�and�stan-dardized�manner;�via�a� team�structure�and�pro-cess;� with� a� high� degree� of� accountability� andsupervision;� and� utilizing� weekly� telephonicteam�meetings�and�daily�information�system�re-porting.�The�result�is�that�no�single�individual�onthe�team�makes�patient�care�decisions�alone.

Global� satisfaction� of� Franklin� recipients� hasbeen�high�(95%�of�recipients�would�recommendor� highly� recommend� the� program� to� others),suggesting� that� patients� and� families� feel� theirneeds� are� appropriately� met� under� Franklin’scare.�The�Complex�Care�Management�(CCM)�pro-gram�has�consistently�demonstrated�a�return�oninvestment�of�1.8� to�1,�which� is�realized� largelythrough�reductions� in�hospitalizations� and�pro-cedures.24 These�data�underscore�the�attraction�ofthe�case�management�model�of�care�for�the�sick-est�and�costliest�patients� to�health�plans,� corpo-rate� insurers,�and�Medicare�providers,�and�sup-ports� the� logic� of� building� upon� the� existingstructure�of�case�management�programs�as�an�ef-ficient�and�appropriate�locus�for�application�of�apalliative�care�intervention.

PROGRAM�DESIGN

Intervention

The�initial�project�design�established�four�spe-cific�objectives:�(1)�To�develop�training�modules

MEIER�ET�AL.122


for�case�management�nurses�on�palliative�care�as-sessment,� identification� and� implementation� oftreatment� interventions,� and� approaches� tophysician�feedback;�(2)�To�provide�formal�pallia-tive� care� assessment� with� structured� feedbackand�recommendations�for�physicians�whose�pa-tients�are�enrolled� in�the�complex�care�manage-ment�program;�(3)�To�compare�outcomes�for�in-tervention� patients� receiving� palliative� careassessment�plus�case�management�versus�controlpatients� receiving� standard� case� managementalone;� and� (4)� To� assess� the� feasibility� and� ac-ceptability�of�this�model�to�patients,�family�care-givers,�health�professionals,�and�industry.�Thesefour�objectives�were�implemented�in�three�phasesover�a� period�of�39�months�(October� 1,� 1998� toDecember�31,�2001).

Phase�1:� (October�1,�1998).�Case-based�trainingmodule�materials�and�in-service�practice�sessionswere�developed�to�ensure�the�expertise�of�thoseFranklin� care� coordinator� nurses� who� were� as-signed�to�the�intervention�group.�The�training�fo-cused�on�the�conduct,�delivery,�and�implementa-tion�of�palliative� care� assessment�and�treatmentprotocols�(Fig.�4).25,26 Computerized�protocols�forthe� assessment� instruments,� subsequent� treat-ment�recommendations,�and�guidelines� for�pro-

viding�feedback�and�recommendations�to�physi-cians�were�developed,�reviewed�by�focus�groups,and� piloted.� Explicit� stepped-care� pathways� ortreatment� alternatives� were� also� developed� foreach� physical� symptom�assessed,� for�psychoso-cial,�spiritual,�or�existential�concerns�identified�onthe� Quality� of� Life� Index,27 and� for� identifiedcommunication�and�advance�care�planning�pref-erences.�These�treatment�and�follow-up�protocolswere�reviewed�and�modified�with�Franklin�nurs-ing�staff�as�part�of�the�development�and�pilotingprocess�in�phase�1.�The�treatment�protocols�wereplaced� on� the� Franklin� Web-based� informationsystem�with�appropriate�Web�links.�For�example,if�severe�pain� is� identified,� the�nurse�is�broughtto�the�protocol�section�focused�on�choices�of�opi-ate�analgesics�and�routes�of�administration;�andcan�click�on�links�to�opiate�conversion�tables�andstandard�bowel�regimens.�Instruments�for�evalu-ation�of�acceptability�and�utility�of�the�interven-tion� to� patients,� family,� nurses,� and� treatingphysicians�were�also�developed�during�phase�1.

Phase�2:�(November�1,�1999�to�December�31,�2001).All�patients�(cared�for�by�control�and�interventionnurses)� were� selected� for� the� CCM� programthrough�a�multiple�step�screening�process�(Fig.�5).

The�process�of�entering� the�Franklin� Complex


FIG.�3. The�Franklin�Health�Clinical�Team.

FHICare

Coordinator

Patient�&Treating

Physician

FHIClinicalAccountManager

��Care�Coordinator�nurse–�Primary�contact�for�patients/family/providers/plan�case�managers–�Talks�to�patient�before�they�make�care�plan�choices�to�help��them�make�the�best�choice�for�themselves–�Lives�in/near�patient’s�community�(9�Care�Coordinators�in�South��Carolina;�50�across�continental�US)–�Meets�every�patient�&�family�at�home/facility�and��provides�additional�visits�as�needed–�Case�load:�20�patients–�35–40�hours�per�case�(5�month�average�case�length)

FHIAccount

Physician

��Clinical�Account�Manager–�Provides�case�direction/collaboration�to�CC�and�acts��as�a�daily�resource�to�ensure�the�big�picture�is�in�view–�Represents�client’s�business�perspective–�Interfaces�with�on-site�plan�clinical�liaison–�Assesses�financial�impact�and�measurement–�Case�load:�80�patients

��Physician�Manager–�Performs�weekly�case�reviews�with�team�to�anticipate�issues–�Communicates�with�treating�physicians�and�plan�physicians��as�needed�to�offer�support�and�solutions–�Provides�medical�perspective�as�only�an�actively�practicing�clinician�can–�Case�load:�100�patients


Care�Program�was�the�same�for�both�control�andintervention�patients.�Initial�visits�by�care�coordi-nators�took�place�primarily�at�home.�The�case�man-agement�system�was�explained�in�detail,�and�a�vol-untary�patient�informed�consent�was�obtained�forparticipation� in�both� the�Franklin�Complex�CareProgram�and�the�study.�After�a�standardized�base-line�assessment�(Fig.�6),�an�initial�evaluation�sum-mary� was� prepared,� and� a� care� plan� was� devel-oped�and�discussed�with�the�patient/family.�Afterdocumentation�of�the�patient’s�and�family’s�choices,a�treatment�plan�was�formulated�based�upon�pa-tient�goals,� actions�needed,� outcomes,�providers,medications,�and�services.

A�total�of�321�Franklin� complex�case�manage-ment�patients�were�enrolled�in�the�study�and�re-ceived�either�usual�case�management�(169�control)(Figs.�3,�5,�and�6)�or�case�management� enhancedby�palliative�care�assessment�and�physician�feed-back/recommendation� protocols� (152� interven-tion;�Fig.�7).�Care�Coordinator�nurses�were�ran-domly� assigned� to� provide� either� usual� casemanagement�(4�nurses)�or�the�palliative�care�en-hanced� intervention� (5� nurses)� Clinical� assess-ments� for� all� patients� were� tracked� using� theFranklin�Personal�Path�Care�Management�System(PCMS),�which�tracks�information�related�to�a�pa-tient’s� enrollment,� assessments� and� outcomes.

MEIER�ET�AL.124

FIG.�4. Training�program�content:�1.5�days.

FIG.�5. Patient�identification�and�selection.


This�database� is�one�of�the�largest�of�its�kind�inthe�United�States�and�uses�a�sophisticated�systemof�issues�identification,�goal�setting,�action�track-ing,� and� outcomes� assessment.� Additional� as-sessment� data� for� the� study� were� also� tracked(Fig.�8).

For�intervention�cases�only�(Fig.�7),�the�follow-ing� additional� assessment� instruments� wereused:�(1)�The�Franklin�Health�Communication�In-strument�(questions�derived�from�the�Toolkit28),was�used�to�assess�patients’�interest�in�discussingend-of-life�care�with�their�family�and�physicians,

and�in�appointing�a�health�care�agent;�(2)�The�Ed-monton� Symptom� Assessment� Scale� (ESAS),29

modified�from�a�10-cm�visual�analogue�scale�to�afour-point�numeric�rating�scale�(none�to�severe),served�to�assess�symptoms�(activity,�anxiety,�ap-petite,�constipation,�depression,�physical�discom-fort,�dyspnea,�fatigue,�pain,�nausea,�and�well�be-ing).�Symptom�assessment�was�conducted�every2�weeks�for�patients�who�were�stable�and�not�ex-periencing� distressing� symptoms� (defined� asmoderate�or�severe).�If�moderate�or�severe�symp-toms�were�identified,�assessment�was�carried�out


FIG.�6. Franklin�Health�baseline�assessment� instrument.

FIG.�7. Intervention�group.


weekly�(or�more�often)�at�the�discretion�of�the�in-tervention�care�coordinator�nurse�and�the�clinicalaccount� manager.� Treatment� recommendationsbased�on�the� computerized� protocols�were� tele-phoned� in� to� the� primary� physician’s�office� forsymptoms�ranked�as�moderate�or�severe,�or�if�apatient�expressed�a�desire�to�discuss�goals�of�carewith�the�physician.�In�the�case�of�specific�medicaltreatment�recommendations�(such�as�a�new�pre-scription�medication),�either�the�nurse�care�coor-dinator� or� the�Franklin� physician� case� managermade�a�direct�call�to�the�treating�physician.

For�control�patients,� the� initial� assessment� in-cludes� questions� regarding� general� health� stateand�advanced�care�planning.� These�queries,� didnot� use� the� formalized� assessment� instrumentsused�by�the�intervention�nurses,�nor�were�they�re-peated�on�a�regular�basis.�Treatment�of�any�symp-toms�identified�by�control�nurses�were�left�to�theclinical�judgment�of�the�nurse�and�CCM�team,�andwere�not�directed�by� the�specific� treatment� pro-tocols�developed�for�the�intervention�group.

All�patients�were�followed�until�death�or�caseclosure.� Fig.� 9� describes� patient� and� data� flowthrough�the�study.�Within�2–7�working�days�af-ter�a� case�was�opened,�all� patients� (control�andintervention)� received� a� brief� telephone� assess-ment� of� symptom� burden� using� the� modified

ESAS�only.�This�survey�was�conducted�by�studystaff�blinded�to�the�assignment�group�of�the�pa-tient.�This�blinded�telephone�assessment�of�symp-toms�was�repeated�for�all�subjects�6–8�weeks�af-ter� the� initial� baseline� telephone� assessment.Patient�and�family�satisfaction�was�assessed�3–8weeks�after�case�closure�(or�death)�using�FranklinHealth’s� standard� instrument� (,www.mor-pace.com/customer-satisfaction.htm.)� with� theaddition�of�global�quality�of�life�questions�in�thephysical�and�emotional�domains.

Phase�3.�The�study�is�currently�in�phase�3,�com-pleting� run-out�of�subjects�still� in� case�manage-ment�in�the�intervention�and�control�groups,�andanalyzing�phase�2�data�in�terms�of�both�patient-centered�outcomes�(pain�and�symptoms,�qualityof� life,� communications�about� treatment� prefer-ences,�satisfaction)�and�utilization�criteria�(hospi-tal�days,� case�management�days,� in-patient� andout-patient�services,�location�of�death,�hospice�re-ferral)�(Fig.�8).

Innovation

This�project�was�conceived�in�response�to�thepressing� need� for� the� integration� of� palliativecare� into� the� services� offered� to� a� seriously� ill

MEIER�ET�AL.126

FIG.�8. Patient�and�data�flow.


population� living� at� home� or� being� cared� foracross� multiple� settings.� While� our� approachwas� derived� from� preexisting� models� of� com-plex� case�management� and�hospital-based� pal-liative�care,�we�discuss�here�innovative�three�as-pects�of�the�project:

Industry/academic� partnership.� For� FranklinHealth� Inc.,� partnership� with� Mount� Sinai� pre-sented�an�opportunity�to�develop�a�better�modelof�care,�quantify�and�report�on�the�improvement,and�use�the�results�to�attract�a�larger�client�base.For� Mount� Sinai’s� Palliative� Care� Program,� theproject�was�a�vehicle�to�export�palliative�care�outof�the�hospital�or�office,�and�into�the�home�set-ting�where� the� majority�of�seriously� ill� patientsreside.�Each�partner� relied� on�the� skills� and�re-sources�of�the�other�to�achieve�shared�objectives.Franklin�Health�provided�the�existing�platform�oftheir�CCM�model,�a�connection�to�a�patient�pop-ulation�with� serious� illness� and�complex�needs,and� an� insurance� client,� Blue� Cross� and� BlueShield�of�South�Carolina,�who�was�willing�to�par-ticipate�in�the�project.�The�investigators�at�MountSinai�School�of�Medicine� contributed�the�educa-tional,� clinical� and�research� expertise� needed� todesign,�implement�and�evaluate�the�intervention.

Training� of�CCM�nurses.�A�second�distinctivecomponent� of� this� project�was� the� training� of-fered�to�the�nurse�care�managers�concerning�(1)

administration� of� formal� assessment� instru-ments;� (2)�use� of� the� assessment� results� to�de-velop�appropriate� treatment� recommendations;and�(3)�employment�of�a�variety�of�strategies�tocommunicate� effectively� with� busy,� treatingphysicians�(Fig.�4).�Not�only�were�the�nurse�caremanagers� empowered� to� identify� patient� dis-tress�in�this�study,�but�they�were�also�given�re-sponsibility� to�do�something� about� it.� In�othercase�management�models,�unmet�patient�needsmay�or�may�not�be� identified.� When�a�need� isidentified,�nurses�may�not�have�the�knowledge,the� confidence,� nor� the� authority� to� devise� anappropriate� intervention.� The� palliative� caretraining�of�Franklin’s�nurses,�and�the�project�de-sign,� explicitly� set� out� to:� (1)� formally� and� re-peatedly� screen� for� a� wide� range� of� symptomdistress� and� (2)� provide� nurses� with� detailedcomputerized� treatment� protocols� so� that� asymptom,� once� identified,� could� be� effectivelyaddressed� by� the� nurse,� with� the� support� andguidance� of� the� FHI� clinical� account� managerand�physician�case�manager,� and�in�discussionwith�the�patient’s�treating�physician.

Encouragement� and� facilitation� of� physician� in-volvement.� The� complex� case� management� pluspalliative� care� program� encouraged� a� strongworking�relationship�with�the�treating�physician,focusing� on� supporting� and� implementing� thephysician’s�efforts�to�provide�good�care�for�their


FIG.�9. Outcome�measures.


complex� patients,� and� creating� an� incentive� forphysicians�to�actually�make�use�of�the�results�ofthe� palliative� care� assessment� protocol.� Thenurse’s�role�was�conceptualized�as�a�support�forboth�patient� and� family� and� the� treating� physi-cian.� Through� the� routine� identification� of� im-portant�clinical� issues�and�the�hands-on�supportfor�whatever�intervention�the�physician�decidedon,�the�nurse�enhanced�the�physician’s�ability�toprovide� meticulous,� high-quality� care� to� seri-ously�ill�persons�living�at�home.�None�of�the�casemanagement�nurses�conceptualized�their�role�asprimarily� focused� on� cost� savings,� but� ratherworked�together�to�achieve�a�common�goal—op-timal�care�of�the�patient�and�family.

PROGRAM�EVOLUTION

Challenges�encountered/strategic�responses

As�the�study�progressed,�a�series�of�challengesprompted�modification�of�the�design�and�imple-mentation�of�the�study,�as�follows:

1. Finding� the� right� partnership:� The� first� majorchallenge�was�to�put�together�a�viable�researchpartnership�comprised�of�an�academic�institu-tion,�a�commercial�health�insurance�plan,�anda� case� management� service� organization.� Inthe�rapidly�changing�health�care�environment,it�was�important�to�identify�a�partnership�thatwould�be�stable�over�the�period�of�the�researchproject.� The� original� proposal� paired� MountSinai�School�of�Medicine�with�Oxford�HealthPlans�and�Franklin�Health,�Inc.�But�because�ofeconomic�difficulties,� Oxford�abandoned� thebusiness�of�Medicare�Managed�Care�targetedby� this� study� and,� in� addition,� ended� manyvendor�contracts,�including�that�with�FranklinHealth,� Inc.�After�Oxford�withdrew�from�theproposed�study,�Franklin�reviewed�their�clientlist�and�proposed�replacing�Oxford�with�BlueCross�Blue�Shield�of�South�Carolina,�and�thisinsurer� was� willing� to� participate� in� the� re-search�study.

2. Adjustment� in� Patient�Population:� The�originalproposal�targeted�a�Medicare-risk�population.The� new� project� partner,� Blue� Cross� BlueShield�of�South�Carolina,�had�a�commerciallyinsured,�employed�population�that�met�the�cri-teria�for�the�study,�but�with�one�major�differ-

ence:�according�to�Franklin’s�prior�experiencein� the� field,� the� number� of� commercially� in-sured� individuals� requiring� complex� casemanagement� was� one� tenth� that� seen� in� theMedicare�population,�and�a�higher�proportionof� those� targeted� for� complex� care� manage-ment�recovered�sufficiently�from�the�illness�tono�longer�require� it.�As�a� result,� the�numberof� patients� participating� in� this� commercialplan�who�were�terminally�ill�was�much�lowerthan� that�originally� projected� for�a�Medicarepopulation.� The� focus�of�the�project�was�ad-justed�to�compensate�for�this�change�in�the�di-agnoses�and�life�expectancy�rates�of�the�newtarget� population.� The� emphasis� was� shiftedfrom� demonstrating� the� impact� of� palliativecare�on�the�care�of�terminally�ill�patients�to�de-livering�palliative�care�to�seriously�ill�patientsindependent�of�prognosis.

3. Difficulty� reaching� and� communicating� withphysicians:�Intervention�nurses�reported�persis-tent�problems�with�reaching�treating�physiciansdirectly�to�discuss�symptom�management�pro-tocols.�In�response�to�these�encounters,�a�CD-ROM�entitled�A�Practical�Guide� to�Communica-tion�Skills�in�Clinical�Practice30 was�given�to�eachprogram�case�management�nurse.�A�review�ofthe� literature� was�also�conducted�to�developevidence-based� one-page� physician� informa-tion�sheets�on�palliative� care� symptom�man-agement�for�anorexia/cachexia,�dyspnea,�con-stipation,� fatigue,� and� nausea� and� vomiting.The�purpose�of�these�information�sheets�wasto� enrich� the� support� given� to� interventionnurses�as�they�attempted�to�make�recommen-dations�to�primary�physicians�about�symptommanagement.� These� one-page� referencedtreatment�summaries�were�distributed�by�faxto�the�physician’s�office�at�the�time�of�the�tele-phone�call.�The�goal�of�this�educational�strat-egy�was�to�encourage�and�support�physiciansin�the�use�of�sometimes�unfamiliar� therapies(such�as� dexamethasone� or�methylphenidatefor�fatigue).

4. When� necessary,� and� upon� request� of� thecase�management�nurses,�the�Franklin�Physi-cian� Case� Manager� telephoned� directly� toSouth�Carolina� treating�physicians� to�discussnew�therapeutic�recommendations.

4. Accrual�of�study�subjects�took�longer�than�antic-ipated:�Because�of�slower�than�anticipated�ac-crual� of� new� patients� in� the� South� Carolina

MEIER�ET�AL.128


Blue�Cross�Blue�Shield�and�Companion�HealthServices�client�base,�the�enrollment�of�the�322patients� included� in� this� study� took� longerthan� expected� and� required� extension� of� thesubject�entry�period.

5. Difficulty�obtaining�program�evaluations�from�pri-mary�physicians:�The�program�evaluation�staffhad�difficulty�contacting�the�physician�directlyfor� their� evaluation� of� Franklin’s� service� totheir�patients.�Staff�were�often�directed�by�of-fice� nurses� and� managers� to� fax� the� form� tothe� physician’s� office,� an� action� which� onlyrarely� resulted� in� a� returned� and� completedsurvey.�Specific�impediments�to�a�better�physi-cian�response�rate�were�not�documented.�It�islikely� that,� in� the�busy�medical� practices� wecontacted,�survey�completion�was�given�a�lowpriority.

Evaluation

Initial� evaluation� design� and� plan.� This� projectwas� designed� to� test� the� hypothesis� that� incor-poration�of�routine�palliative�care�assessment�andsupport�for�patient�family�centered�care�planningand�decision�making,�with�practical�feedback�andsupport� for� physicians� regarding� implementa-tion,�can�be�a�feasible�and�effective�component�ofhome-based� (as� opposed� to� office-� and� institu-tional-based)� complex� case� management� pro-grams.�The�objective�of�our�evaluation�plan�wasto�examine� the�effectiveness�of�this� interventionby�comparing�clinical�and�utilization�outcomes�toa� control�group�of�patients� receiving� case�man-agement� only.� Although� it� would� have� beenmethodologically� ideal� to�randomize� individualpatients,�the�fact�that�Franklin�Health�was�alreadyusing�a�CCM�model�affected�how�the� interven-tion�and�control�group�were�devised.�Early�in�theplanning�stages�of�the�project,�for�example,�a�de-cision�was�made�that�the�study�would�not�com-pare� the�intervention�to�no�case�management� atall.�Subsequently�the�investigators�devised�a�com-parison�between�the�existing�Franklin�CCM�pro-gram� (CCM� control)� and� Franklin� Plus� (CCMplus� palliative� care� assessment� and� feedback:CCM1).

The� evaluation� itself� focuses�on� three� criticalareas:� patient� centered� outcomes,�provider� out-comes,�and�utilization�of�medical�resources.�Pri-mary�outcome�measures�selected�for�patients�andfamilies� include:� (1)� percent� of� eligible� patients

who�agreed� to�participate� and� in�whom�the� in-tervention� assessment� process� could� be� com-pleted;�(2)�results�of�the�assessment�instruments;(3)�the�feasibility�and�acceptability�of�the�processto�the�participants;�and�(4)�the�impact�on�patientcare�of�the�intervention�nurse�feedback�to�physi-cians� concerning� assessment� results,� treatmentrecommendations,�and�support�for�implementa-tion�of�a�palliative�care�plan.

Assessment� instruments� and� outcome� measures.The� original� evaluation� plan� included� four� as-sessment�instruments�employed� to�measure�pa-tient/family�outcomes�(Fig.�9):

� Modified� Edmonton� Symptom� AssessmentScale,28 converted�from�a�visual�analogue�scaleto�a�numeric�rating�scale�(0,�none�to�3,�severe)to�facilitate� telephonic�use.�The�ESAS�assessespain,� shortness� of� breath,� appetite,� nausea,sense�of�well-being,�activity�level,�fatigue,�anx-iety,� and� depression.� Five� questions� wereadded� to� the� original� ESAS� (pain� now;� painover�last�3�days;�acceptability� of�pain�control;level�of�constipation;�time�of�last�bowel�move-ment).

� Missoula-VITAS� 16-Item� Quality-of-Life� In-dex:� A� 16-item� survey� with� a� 5-point� Likertscale� that�assesses�quality�of�life� across�5�do-mains.27

� Morpace� Satisfaction� Instrument:� Telephonicsatisfaction� survey�of� individuals� whose�caremanagement� plan� has� been� completed.� Sur-veys�are�conducted�by�independent�market�re-search� and� consulting� organization,� MorpaceInternational,�Inc.16

� Advance� Care� Planning� Questionnaire:� Aneight-question� instrument� modified� from� theToolkit28 that� was� used� to� assess�patient’s� in-terest� both� in� discussing� end-of-life� care� withtheir�family�and�physicians�and�in�appointing�ahealth� care� agent.� Questions� included� yes/noqueries� about� specific� wishes� for� care;� priorcommunication�with�family�or�physician;�desirefor� communication� with� family� or� physician;prior�completion�of�an�advance�directive;�desireto�discuss�the�advance�care�planning�process.

� The�provider�outcome�measures�explored�theacceptability�and�feasibility�of�this�interventionfor�the�nursing�and�medical� staff,�and� indus-try�participants.�Physicians,�for�example,�werequeried�for�their�opinion�on�the�utility�and�ben-



efit�of�the� intervention�for�their�patients.�Fivequestions�were�included�in�the�physician�sur-vey:

1. Did�you�find�the�assessments�and�recommen-dations�helpful?

2. Did�you�follow�any�of�them?3. Did� the�case�management� team�help� in� their

implementation?4. Did�you�perceive�those�recommendations�you

followed�to�improve�the�care�of�your�patient?5. Would� you� like� to� have� future� patients� en-

rolled�in�this�type�of�program?

Finally,� measures� of� utilization� were� trackedduring� the� study:� hospital� days,� intensive� careunit� (ICU)� days,� emergency� department� use,physician� visits,� length� of� stay� in� complex� caremanagement,�physician�inpatient�and�outpatientrelative�value�units�(RVUs),�hospice�referral�rate,home� care� services� used,� analgesic/anxiolytic/antidepressant�prescribing,�and�site�of�death.

Adjustment�of�evaluation�plan�and�instruments.�Theevaluation�plan�required�adjustment�in�the�assess-ment� tools.� The� Missoula-VITAS� Quality-of-LifeIndex�was�eliminated�as�a�result�of�feedback�fromnurses�during�the�piloting�of�the�assessment�pack-age.�The�nurses�felt�that�the�instrument�was�mostappropriate�in�a�terminally�ill�population�who�hadacknowledged�the�fact�that�they�were�dying.�Only30%� of� patients� in� this� project� died� during� casemanagement.� Most� recovered� sufficiently� fromtheir�illness�to�no�longer�need�complex�case�man-agement� or� an� adequate� long-term� managementplan� was�put� in�place.� As�a� result,� routine�ques-tions�focused�on�facing�death�were�neither�appro-priate�nor�well-tolerated�by�the�majority�of�studysubjects.�Instead,�two�questions�were�added�whichassessed�Franklin�Health’s�performance�in�terms�ofpatient/family�perception�of�improvement�in�theirquality�of�life�as�the�result�of�the�intervention.

Overall,� has� Franklin� Health� improvedyour/the�patient’s�quality�of�life?

What� could� we� do� to� make� the� FranklinHealth� Program� more� helpful� to� improveyour/the�patient’s�quality�of�life?

A�second�minor�adjustment�involved�the�mod-ified�ESAS.�Because�of�the�prevalence� of�consti-pation�as�a�side�effect�of�the�use�of�opiates,�two

questions�about�constipation�as�a�symptom�wereadded.� In� addition,� patients� were� asked� threequestions� about� pain� (as� opposed� to� the� singlequestion�included�on�the�unmodified�ESAS):�cur-rent�levels�of�pain,�pain�over�the�last�three�days,and�acceptability�of�pain�control.

Randomization.�Because�Franklin�Health�was�al-ready�using�a�CCM�model,�the�risk�that�care�of�in-tervention�patients� would� influence� or� contami-nate� the� care� of� control� patients� treated� by� thesame�clinical�coordinator�nurse�was�high.�This�is-sue� affected� how� the� intervention� and� controlgroups�were�devised.�To�reduce�the�risk�of�cont-amination,� two�completely� separate�CCM�teamswith�separate�physician�case�managers�and�clini-cal�account�managers�were�created.�The�approxi-mately� 10� South� Carolina� clinical� coordinatornurses�were�then�randomly�assigned�to�the�con-trol�team�(usual�CCM)�or�intervention�team�(CCM1 palliative�care�assessment�and�feedback).

Final� evaluation� of� nurses’� assessment� of� theprogram�(in�both�intervention�and�control�groups)will�be�conducted�once�run-out�of�the�final�studypatients� is�complete.�Exit�interviews�with� indus-try�(South�Carolina�Blue�Cross�Blue�Shield)�staffwill�also�be�conducted�once�run-out�is�complete.

DISCUSSION

Results

Demographics�of�study�subjects�may�be�foundin�Table�1.�The�study�is�currently�in�the�evalua-tion�and�analysis�phase,�and�therefore�final�clin-ical�and�utilization�results�are�not�currently�avail-able.� The� ensuing� discussion� of� the� project� isbased� upon� preliminary� data,� interviews� withstakeholders,�and�field�observations.

Feasibility�of�the�programmatic�intervention:

Industry.�Complex�patients�typically� representa� subset� within� the� top� 1%� of� high� utilizers� ofhealth�care�resources.�The�ability� to�manage�thecare�of�these�high-risk�patients�carefully,�therebyexerting�some�control�over�the�costs�involved,�ispart� of� responsible� management� of� health� careand�is�critical� to�the�fiscal�viability�of�the�healthcare�industry�(Figs.�1�and�2).�Prior�to�this�study,Franklin�Health�had�implemented�and�refined�aCCM�program�to�work�with�this�group�of�outlierpatients.� It� was� relatively� easy� for� the� research

MEIER�ET�AL.130


team�to�integrate�a�palliative�care�focus�into�thispreexisting,�intensive,�and�highly�structured�casemanagement� platform.� The� resulting� deliverymodel�has�now�been�field�tested�and�refined�as�aproduct�ready�to�be�utilized�by�other�health�plansand�their�case�management�services.

Because� of� their� experience� with� this� model,and�Franklin’s�belief� in�the�value-added�dimen-sion� of� the� palliative� care� component,� the� pro-gram� has� been� rolled� out� to� Franklin’s� entireclient�base.�This�decision�was�based�on�two�fac-tors:�(1)�preliminary�evaluation�of�the�study�datashowed� a� trend� toward� improved� patient� careand� patient� satisfaction� without� an� increase� inprogram� costs� and� (2)� increasing� industry� de-mand�for�case�management�services� incorporat-ing�a�palliative�care�focus.

Patients� and� families.� The� Franklin� CCM� pro-gram� was� designed� to� function� in� an� advocacymode,�incorporating�the�following�benefits�to�pa-tient�and�family:

1. Provides� information� and� professional� sup-port�for�patient�decision-making;

2. Supports�and�guides�the�patient�and�family�intheir�relationship�to�the�health�care�system;

3. Offers�case�management�services�to�secure�accessand� oversee� the� quality� of� services� deliveredwithin�a�physician-directed�plan�of�care;

4. Remains� available� to� patients� and� familiesthrough�the�entire�course�of�the�illness,�even�ifthere�is�a�change�in�setting�or�geography.

Because�of�the�addition�of�routine�and�formalpalliative�care�assessment�and�feed-back�to�theirphysician�in�the�areas�of�pain�and�symptom�man-agement�and�psychosocial�support,�patients�andfamilies� in� this� study� received� health� care� thatwas� calibrated� to�match� the� intensity� and� com-plexity� of�their�needs.� We�hope� to�demonstratethat�it�is�also�effective�in�terms�of�clinical�and�uti-lization�outcomes.

Clinicians.�Materials� developed� for�this�projectare�simple�to�use,� feasible� in�the�real� clinical� set-

ting,�and�of�specific�value�to�the�doctors�and�nursesactually�taking�care�of�the�patient.�This�emphasison�relevance�and�practicality�was�intended�to�max-imize�the�chances�that�recommendations�based�onthe�assessment�protocol�would�actually�be�imple-mented�by�the�patient�and�physician,�with�the�sup-port�of�the�case�management�nurse.�The�nurse�casemanagers� were� enthusiastic� about� the� palliativecare� training,� describing� themselves� as� empow-ered�by�the�new�knowledge,�the�requirement� forconduct�of�regular� symptom�assessment,� and�anenhanced�role�definition� that�included�taking�re-sponsibility� for�initiating� action�when�a�problemwas�identified.�With�the�special�training,�comput-erized�treatment�guidelines,�and�the�Franklin�ap-proach�(field�nurses�are�supported�in�their�workby�the�weekly�team�case�discussions�and�constantteam�contact�through�Franklin�Health�InformationSystems),�nurses�could�engage�in�comprehensiveclinical�assessment�because�they�knew�with�confi-dence�what�to�do�in�response�to�a�problem�iden-tified�as�a� result� of�their� assessment�and�specifi-cally,�what�interventions�to�recommend�when�theycontacted�the�treating�physician�by�telephone.

Acceptability�and�sustainability�of�the�interventionamong�the�“key�stakeholder�groups”�(patients,�families,clinicians,� institutions).� Preliminary� reports� haveindicated�that�this�model�is�feasible,�and�that�it�in-creases�the�level�of�patient�and�family�satisfactionwith�care.�The�actual�assessment�data�from�the�pa-tient/family� and� physician� surveys� is� currentlybeing� gathered� and�analyzed.� There� is� evidencefrom�other�sources,�however,�which�demonstratesa�strong�positive� reaction�among�key�stakehold-ers.�Blue�Cross�Blue�Shield�of�South�Carolina,�forexample,� has� consistently� demonstrated� an� en-thusiasm�for�the�program�and�an�interest�in�con-tinuing�their�participation�in�the�project.�FranklinHealth,� Inc.’s�decision� to� integrate� the�palliativecare� intervention� module� into� the� program� of-fered�to�their�entire�client�roster�nationwide�is,�infact,�the�strongest�evidence�of�feasibility,� accept-ability� and�perceived� value� of� this� intervention,suggesting�that�the�palliative�care�intervention�hasenhanced�the�ability�of�Franklin�Health�to�marketits�services�to�prospective�consumers.

Generalizability

The� CCM� approach� described� here� is� flexibleand�can�be�applied� to�a�range�of�patient�popula-tions�in�a�variety�of�plan�arrangements.�The�pre-


TABLE 1. DEMOGRAPHICS OF STUDY SUBJECTS

Control Interventionn 5 169 n 5 152

Average�age 48.6 47.6Number�(%)�female 91�(54) 87�(57)Number�(%)�with�cancer 124�(73) 118�(78)


dictable�instability�of�the�health�care�market�doesnot�preclude�the�use�of�this�clinical�model.�Becausethe�model�depends�on�existing�nursing�staff�eval-uations,�communications�with�treating�physicians,implementation of�treatment�plans,�and�the�avail-ability�of�computerized�information�support�sys-tems,� it� can� be� also� integrated� into� a� variety� ofother�types�of�care�systems�including�traditionalvisiting� nurse� home� care� programs,� PACE�pro-grams,� fee-for-service,�and�medical� staff�or�pro-vider-based�organizations.

This�protocol�will�be�posted�on�the�website�ofthe�Center� to�Advance�Palliative� Care� (,www.capc.org.).�The�palliative�care�assessment�tools,training� modules� for�nurse�case�managers,� pro-tocol�guidelines�for�treatment�recommendations,and�patient� and�professional�satisfaction� instru-ments�will�also�be�made�available.

Implications

Significant� instability� exists� in� the�health� carearea�in�general—on�the�policy�level,�in�the�field,and�in�the�insurance�and�managed�care�industryitself.�This�instability� has�a�direct�impact�on�theeffort� to� conduct� the� type� of� rigorous� researchneeded�to�improve�the�quality�of�care.

The�second�insight�gained�from�this�project�fo-cuses� on� the� importance� of�empowering� healthprofessionals� to� act� on� behalf� of� their� patients.This� observation� was� prompted� by� the� unex-pected� enthusiasm� and� positive� reaction� of� theteam�nurses,�who�despite� their� training� in�com-plex� care� management,� gained� confidence� andinitiative� in� the� management� of�patient� distressas�a�result�of�the�palliative� care�assessment�andintervention�modules.�Over�a�relatively�short�pe-riod� of� time,� they� collectively� progressed� fromsome� skepticism� and� insecurity� about� these� as-sessments�and�interventions�to�an�attitude�of�en-thusiasm�and�excitement�about�the�effectivenessof�their�new�clinical�skills.

The�investigators�theorize�that�even�though�theteam�nurses�had�been�routinely�confronted�withpalliative� care� issues,� they�had� not�had� the�op-portunity�to�implement�a�formal,�structured�pal-liative�care�assessment�and�feedback�approach�atthis�level�of�intensity.�More�importantly,�they�hadnot�previously�been�in�the�position�of�making�thespecific� recommendations� to� the� treating� physi-cians�that�they�were�trained�to�provide�in�this�pro-gram.�As�a�result�of�this�project,�the�nurses�were

empowered�to�be�more�assertive�and�directive�asadvocates�for�their�patients�who�were�suffering—and�they�were�given�the�information�necessary�toback�up�their�observations�and�their�recommen-dations.� This� model� is� powerful� because� it� en-ables�physicians�and�nurses�to�do�a�better�job,�re-inforced� by� their� perception� that� the� patientsactually�benefit�as�a�result.

Limitations

Limitations�of�this�study�include�the�fact�thatsatisfaction� rates� with� the� Franklin� Care� Man-agement�Program�were�extremely�high�(95%)�atbaseline,� thus�reducing�the�chances�that�a�statis-tically� significant� difference� (at� least� in�a�globalsatisfaction�measure)�will�be�detected.�Second,�al-though� there�may� be� significant� differences� be-tween� the�randomized�nursing�groups�in�termsof�experience,� training� and�attitudes,� their� levelof� education� was� similar� and� nurses� in� bothgroups�had�at� least�8�years�of�prior�nursing�ex-perience.�Third,�biases�may�result� from�nonran-domization�of�individual�patients.

New�directions

This�project�has�the�potential� to�affect�the�de-livery�of�care�significantly�near�the�end�of�life�be-cause� it� exploits� a� preexisting� and� successfulstructure� for� delivering� care� to� the� sickest� andmost� complex� patients.� Because� of� the� steadygrowth�of�case�management�as�a�means�of�caringfor�complex-high�risk�patients�while� controllingresource�utilization,�this�model�is�the�logical�placeto�apply� the�well-developed�processes�of�pallia-tive�care�assessment,�while�utilizing�the�resultingdata� to� stimulate� and� maintain� the� ongoing� in-volvement�of�the�treating�physician�in�the�care�ofthe�patient.�This�model�does�not�require� funda-mental� changes� in� the� reimbursement� structureof�medicine,�nor�in�the�venue�where�care� is�de-livered,�and�could�be�locally�adapted�and�widelyimplemented� in�a�short�period�of�time.�If,�as�weanticipate,� this� project� yields� solid� evidence� ofboth� feasibility� and� effectiveness� in� improvingpatient� outcomes,� the� integration� of� case� man-agement� with� palliative� care� assessment� andfeedback�to�treating�physicians�could�become�animportant�approach�to�community�care�of�the�se-riously� ill� outside� of� formal� hospice� programs.The�project�is�innovative�because�of�its�simplicityand�potential� for�broad�applicability,� utilizing� a

MEIER�ET�AL.132

widely� available� programmatic� approach� en-hanced�by�palliative�care.

ACKNOWLEDGMENTS

This�work�was�supported�by�Promoting�Excel-lence�in�End-of-Life�Care,�a�National�Program�Of-fice�of�The�Robert�Wood�Johnson�Foundation.

Drs.�Meier,�and�Morrison�are�Faculty�Scholarsof� the�Project� on�Death� in�America,� New�York.Dr.� Meier� is� recipient� of� an� Academic� CareerLeadership�Award�(K07�AG00903)�from�the�Na-tional� Institute� on� Aging,� Bethesda,� Maryland.Dr.�Morrison�is�the�recipient�of�a�Mentored�Clin-ical�Scientist�Development�Award�(K08�AG00833)from�the�National� Institute�on�Aging,�Bethesda,Maryland,�and�is�a�Paul�Beeson�Faculty�Scholarin�Aging�Research.

REFERENCES

1. Emanuel� EJ,� Fairclough� DL,� Slutsman� J,� Alpert� H,Baldwin�D,�Emanuel�L:�Assistance�from�family�mem-bers,� friends,� paid�caregivers,� and�volunteers� in� thecare� of� terminally� ill� patients.� N� Engl� J� Med� 1999;341:956–963.

2. Thar� W.�Cost�of�health� care� for� complex�case�man-agement�clients.�Franklin�Health�Incorporated,�1999.,www.franklinhealth.com. (Last�accessed�May�15,2003).

3. Pacala�J,�Boult�C,�Hepburn�K,�Kane�R,�Kane�R:�Casemanagement�of�older�adults.�J�Am�Geriatr�Soc�1995;43:538–542.

4. Boult�C,�Kane�RL,�Brown�R:�Managed�care�of�chron-ically�ill�older�people:�The�US�experience.�BMJ�2000;321:1011–1014.

5. McCorkle�R,�Strumpf�NE,�Nuamah�IF,�Aaler�DC,�Coo-ley�ME,�Jepson�C,�Lusk�EJ,�Torosian�M:�A�specializedhome� care� intervention� improves� survival� amongolder�post-�surgical�cancer�patients.�J�Am�Geriatr�Soc2000;48:1707–1713.

6. Nordmann� A,� Heilmbauer� I,� Walker� T,� Martina� B,Battegay�E:�A�case-management�program�of�mediumintensity�does�not�improve�cardiovascular�risk�factorcontrol�in�coronary�artery�disease�patients:�The�Heart-care�I�trial.�Am�J�Med�2001;110:543–550.

7. Boult�C,�Boult�L,�Pacala�JT:�Systems�of�care�for�olderpopulations� of� the� future.� J� Am� Geriatr� Soc� 1998;46:499–505.

8. American�Geriatrics�Society:�Care�management�posi-tion� statement.� J�Am�Geriatr� Soc�2000;48:1338–1339.

9. HMO�Work� Group�on�Care�Management:� Essentialcomponents�of�geriatric�care�provided�through�healthmaintenance�organizations.�J�Am�Geriatr�Soc�1998;46:303–308.

10. National� Hospice� Organization:� Family� SatisfactionSurvey.�National�Hospice�Organization,�1997.�,www.nhpco.org. (Last�accessed�May�15,�2003).

11. National�Hospice�and� Palliative�Care� Organization:Stats/Research/Resources.� Alexandria,� VA;� 2001.,www.nhpco.org. (Last�accessed�May�15,�2003).

12. Keay�TJ,�Fredman�L,�Taler�GA,�Datta�S,�Levenson�SA:Indicators�of�quality�medical�care�for�the� terminallyill� in� nursing� homes.� J� Am� Geriatr� Soc� 1994;42:853–860.

13. Keay� TJ,� Taler� GA,� Fredman� L,� Levenson� SA:� As-sessing� medical� care� of� dying� residents� in� nursinghomes.�Am�J�Med�Qual�1997;12:51–56.

14. Keay�TJ,�Schonwetter�RS:�The�case�for�hospice�care�inthe� long� term� care� environment.� Clin� Geriatr� Med2000;16:211–223.

15. Meier� DE:� Planning� a�hospital-based�palliative� careprogram:�A�primer�for�Institutional�leaders.�In:�Cen-ter� to� Advance� Palliative� Care,�eds.� Technical�Assis-tance� Series� 1.� New� York:� 2000.� ,www.capc.org.(Last�accessed�May�15,�2003).

16. Morpace� Customer� Satisfaction� Telephonic� Survey.,www.morpace.com/customer-satisfaction.htm.(Last�accessed�May�15,�2003).

17. Morrison�RS,�Siu�AS,�Leipzig�RM,�Cassel�CK,�MeierDE:�The�hard�task�of�improving�quality�measurementat�the�end�of�life.�Arch�Intern�Med�2000;160:743–747.

18. Meier� DE,�Morrison� RS,�Cassel�CK:� Improving� pal-liative�care.�Ann�Intern�Med�1997;127:225–230.

19. Mor�V,�Masterson-Allen�S:�A�comparison�of�hospicevs�conventional� care�of� the� terminally� ill� cancer�pa-tient.�Oncology�1990;4:85–91;�discussion�94,�96.

20. Du�Pen�SL,�Du�Pen�A,�Polissar�N,�Hansberry�J,�Kray-bill�BM,�Stillman�M,�Panke�J,�Everly�R:�Implementingguidelines� for�cancer�pain�management:�Results�of�arandomized� controlled� clinical� trial.� J� Clin� Oncol1999;17:361–370.

21. O’Boyle�CA,�Waldron�D:�Quality�of�life�issues�in�pal-liative�medicine.� J�Neurol� 1997;244(Suppl�4):S18–25.

22. Medicare�Payment�Advisory�Commission:�Improvingcare�at�the�end�of�life.�Report�to�the�Congress:�SelectedMedicare�Issues.�Washington,�D.C.:�1999,�pp.�117–132.

23. Institute� of� Medicine.� Approaching�Death:� ImprovingCare� at� the� End� of� Life.� Washington,� D.C.:� NationalAcademy�of�Sciences,�1997.

24. Franklin� Health:� Program� Outcomes.� ,www.franklinhealth.com,�pro_out.htm. (Last�accessed�May15,�2003).

25. Wrede-Seaman�L:�Symptom�management�algorithmsfor� palliative� care.�Am� J� Hosp�Palliat�Care� 1999;16:517–526.

26. Wrede-Seaman�L:�Symptom�Management�Algorithms�forPalliative�Care.�Yakima,�WA:�Intellicard,�1996.

27. Byock�IR,�Merriman�MP:�Measuring�quality�of�life�forpatients� with� terminal� illness:� the� Missoula-VITASquality�of�life�index.�Palliat�Med�1998;12:231–244.

28. Teno�JM,�Okun�SN,�Casy�V,�Welch�LC:�Toolkit�of�In-struments� to�Measure�End�of�Life�Care� (TIME).�Re-source� Guide:� Achieving� Quality� at� Life’s� End.



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Care for medically complex patients • Case management, social services & discharge planningIV therapy & wound care • Long-term care available

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Case Management Magazine Ad.indd 1 1/20/12 4:00 PM

skilled nursing & reHaB



a Ambulatory

adC Adult Day Care

adH Adult Day Health Care

aL Assisted Living

aLZ Alzheimer’s/Related Dementia Diagnoses

CarF Commission on Accreditation of Rehabilitation Facilities

CC Continuum of Care

CCrC Continuing Care Retirement Community

CHHa Certified Home Health Agency

CM Care Management

Coa Council on Accreditation

daY Day Care

diaL Dialysis

dMe Durable Medical Equipment

Hiv Human Immunodeficiency Virus Care

HBo Hyperbaric oxygen Therapy

HC Home Care

HMo Health Maintenance organization

HoS Hospice Care

iCF Intermediate Care Facility

int Interactive Environment

iv Intravenous Therapy

JCaHo Joint Commission on Accreditation of Healthcare organizations

LtaC Long Term-Acute Care

MC Managed Care

Med Medically Complex

onC oncology Services

ot occupational Therapy

Per Personal Care

PS Pulmonary Services

PT Physical Therapy

rHB Rehabilitation Therapy

rSP Respite Care

rt Respiratory Therapy

SUB Sub-Acute Care

SCU Special Care Unit

SL Senior Living Community

SnF Skilled Nursing Facility

SSi Supplemental Security Income

St Speech Therapy

SU Secured Unit

tCH Tracheostomy Care

tCU Transitional Care Unit

va Veteran’s Administration Contract

vent Ventilator Care/Rehabilitation

WC Wound Care

WSS Wandering Security System

the following is a rubic of abbreviations used throughout Case Management.

ruBic

PL

We specialize in Short-Term Rehabilitation and also offer Long-Term Care.

FeaturingPhysical Therapy | Occupational Therapy | Speech Therapy | IV Therapy

Orthopedic Rehabilitation – Hip/Knee Fractures and ReplacementsStroke Rehabilitation | Wound Management | Tracheotomy Care

Pain Management | Comprehensive Discharge Planning

Lexington PlaceNursing and Rehab*

Aransas,TX 361-758-7686

Community Care CenterHondo,TX

830-426-3087

Kingsland Hills Care Center*

Kingsland, TX 325-388-4538

Windchime at The VillageAssisted LivingKingsland, TX 325-388-3502

Hacienda Oaks at BeevilleBeeville, TX

361-358-5612

Woodridge Nursingand Rehabilitation

Beeville,TX 361-358-8880

Parkview Nursing And Rehab Center*

Fast Track Rehabilitationand RecoveryLockhart,TX 512-398-2362

Kirkwood Manor Nursingand Rehab Center

Fast Track Rehabilitationand Recovery

New Braunfels,TX 830-620-0509

Hacienda Oaks Nursingand Rehab*Seguin,Tx

830-379-3784

Stevens Health Care and Rehab Center*

Yoakum,TX 361-293-3544

Buena Vida Nursingand Rehab CenterSan Antonio,TX

210-333-6815

Oak Park Nursingand Rehab CenterSan Antonio,TX

210-344-8537

*Secured Units available*

case management magazine south central june/july

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