Provider Insider

Care management

| Issue No. 12

Care managers support decreasing cost.

Care managers are part of the value-based health care team. They work in the “in-between spaces” with patients and their providers to identify patients who use the emergency room frequently, and address the root cause for ED overutilization. They provide tools for better managing care needed in the home and educate patients about seeking care at the right time and place.  This has become even more important during the pandemic, as patients are discharged from hospitals and sent home from the ED with higher acuity levels than they were pre-pandemic.  Care managers identify and reach out to those patients who are high risk for readmission and provide them with extra support.

Patients with COVID-19 and anxiety.
Following a diagnosis of COVID-19, and especially a hospitalization for COVID-19, we are seeing high rates of patients with anxiety due to symptoms, stigma and social isolation. The following story highlights how important a care manager can be in addressing this and helping patients feel more confident they are still being cared for, even if they are outside the ED.

ED visit:
Patient was diagnosed with COVID-19 in the ED. Following his visit, he was experiencing shortness of breath, fever and anxiety related to the acute symptoms and diagnosis. He returned to the ED later that same day with the same symptoms.

Care manager call:
Following his ED visits, the patient was contacted by the C3 RN care manager. The patient described having severe anxiety related to his symptoms and diagnosis. He had recognized the need for help and found an outpatient behavior health program and was waiting to be connected with a provider for counseling.

RN care manager intervention:
The RN care manager informed the primary care clinic of patient’s ED visits, diagnosis and his plan to connect with a behavioral health counselor. The care manager also arranged a follow-up visit for the patient with his primary care provider. The care manager supplied the provider with the ED notes and a summary of the conversation with the patient. The care manager confirmed the patient’s follow-up with the psychiatrist and contacted the patient weekly to track symptoms and reinforce the plan of care.

The C3 central care management team works with network practices by outreaching patients following hospitalizations and ED visits. If you want to meet your C3 care manager, please contact Jenn Countryman.