Ethics and patient follow up

[djmatte, ADN, MSN, RN, NP]

Posting this here more for discussion than anything.  At what point do providers get concerned about the frequency of patient follow up as we weigh the bottom line against the necessities of the community?

I recognize this can be highly specific to the location and needs of our individual population. My clinic group can be described IMO as provider-heavy.  We have numerous providers who regularly don't have full schedules and in attempts to close those gaps, one initiative is to ensure all regional ED and urgent care visits are followed up in the clinic.  ED specifically because the goal is to reduce unnecessary ED visits and educate that we are exceptionally open (understandable given the cost of an ED visit).  But I frequently see these urgent care visits within days for something that has been resolved and there's no prior screening to see if this is even a necessary visit.  Now the patient may be pushed to pay another copay for a visit they're told they should have (they rarely say no) and go to a visit where they just receive the same information they received two days before.  Now this may be an unfortunate flaw in our own system as our phone associates are not clinically trained and wouldn't know clinical necessity to justify a follow up.

My concern is that our goals are to reduce the cost of community healthcare are falling flat (and maybe disingenuous).  These patients are brought in multiple times a month/year with minimal need.  We push to see chronic illness patients quarterly and many providers order labs and studies (not cheap) to validate their therapies are or are not working multiple times a year.  Some labs are needed when we start new therapies or there are ancillary problems that may result from certain regimens.  But as I've grown in my own practice, I often feel concern for these patients who are racking up healthcare bills on the basis that providers need to meet those bottom lines.  Often feels pyramid scheme-like to me.

This was probably mostly a vent, but still wanted to set up a discussion on a subject I find interesting.  Thoughts?

[amoLucia]

You make a good point. Am asking do you have any case management or navigator programs in place for these pts? I find I have to determine my need for return visits because I am seeing numerous specialists. And everybody wants everything with little regard for what else is required of me. I have to prioritorize visit/service necessity. Like what is the most critical service I need to address. Right now, I will be coordinating the start of radiation oncology.

One of my providers has a home visiting nurse program just for its specialty - it covers only my specific diagnosis and is meant to prevent yoyo exacerbations or hospitalizations. (Had a MAJOR close call in August.) I've just begun this service - it sounds promising for a vulnerable population, esp in these times as it's free and home-based.  

I believe a CM with a responsible party could coord a better system for care services.

My HC insurance also has a case manager who checks in with me. PT/OT therapy had a case manager; HHA services has a CM. My PMP checks in. Like I have CMs coming out the woodwork!! 

I would guess that I am like most other clients needing extensive services. But I am different in that I can make a more knowledgeable decision based on my nsg educ & exp. Not everyone is like me. I have to finely juggle and orchestrate my care among transportation options, provider appt availability, therapies, other nec home services, etc.

Such a CM program might take quite a bit of planning, but it could def help in the long run for pt wellness and cost concerns.

JMHO

[djmatte, ADN, MSN, RN, NP]

20 minutes ago, amoLucia said:

You make a good point. Am asking do you have any case management or navigator programs in place for these pts? I find I have to determine my need for return visits because I am seeing numerous specialists. And everybody wants everything with little regard for what else is required of me. I have to prioritorize visit/service necessity. Like what is the most critical service I need to address. Right now, I will be coordinating the start of radiation oncology.

 One of my providers has a home visiting nurse program just for its specialty - it covers only my specific diagnosis and is meant to prevent yoyo exacerbations or hospitalizations. (Had a MAJOR close call in August.) I've just begun this service - it sounds promising for a vulnerable population, esp in these times as it's free and home-based.  

I believe a CM with a responsible party could coord a better system for care services.

My HC insurance also has a case manager who checks in with me. PT/OT therapy had a case manager; HHA services has a CM. My PMP checks in. Like I have CMs coming out the woodwork!! 

I would guess that I am like most other clients needing extensive services. But I am different in that I can make a more knowledgeable decision based on my nsg educ & exp. Not everyone is like me. I have to finely juggle and orchestrate my care among transportation options, provider appt availability, therapies, other nec home services, etc.

Such a CM program might take quite a bit of planning, but it could def help in the long run for pt wellness and cost concerns.

JMHO

There is a form of "care management", but it is an ancillary program sponsored by ACOs geared toward specific patient populations.  It's essentially a back-side kick back to the company with the expectation the worst cases are followed up on by dedicated people.  Technically we don't hire care managers per-se to work in this function; just take a provider and have them dedicate certain days to this task.  What ends up happening here unfortunately is the patient comes in to see a provider for CM and then that provider still ends up doing their other job such as med refills and other acute things (even though the company is getting paid for a dedicated CM).  Shady stuff actually which makes me glad I'm not one of those providers.

But that's a whole other ball of wax to get into. 

[amoLucia]

Still sounds like a reeeeal CM program (not a half-a**ED) one is indicated.

 

[djmatte, ADN, MSN, RN, NP]

Just now, amoLucia said:

Still sounds like a reeeeal CM program (not a half-a**ED) one is indicated.

  

No doubt!  I was a care manager when I was an RN at the VA.  But you won't see them spending the coin on it. Sadly.

[WestCoastSunRN, MSN, CNS]

This is the stuff healthcare reform should be made of.

[amoLucia]

2 minutes ago, WestCoastSunRN said:

This is the stuff healthcare reform should be made of.

YES!!

My pet peeve used to be the absolutely UNBELIEVABLE waste re medications in LTC. I was LTC for a loooong time and it was always the same regardless of the facility. BIG PHARM makes the money.

And nobody, even the LTC industry itself, has the clout to oppose BIG PHARM.

Sorry to hijack the thread.