Population Health Management: The Care Manager’s Role

In his nearly 30-year nursing career, Bill Theisen, RN, has helped treat cancer patients, those with HIV, and people recovering from complex orthopedic surgery. He has even worked with patients just after open-heart surgery.

But he says nothing compares to his current role as a care manager at The Phyllis Jen Center, a physician group located within Brigham and Women’s Hospital that treats about 18,000 patients. That’s because as the caregiver overseeing the entire treatment of patients with complex medical conditions, he can have an enormous impact on the way people live.

“This is the future of care,” said Theisen, 51. “I’m linked to the physicians and the social workers and even the front-desk staff in a team-based approach to care. It’s a better way to deliver care to all kinds of patients.”

Theisen coordinates the care of 200 patients, most of them with chronic conditions like diabetes, congestive heart failure or mental illness. In addition to helping physicians treat the patients, he acts as a guide, concierge, advisor, sounding board, detective and navigator – all to ensure that patients get the right care at the right time in the right place.

He tells the story of one patient with a multitude of problems. She was overweight, suffered from congestive heart failure, and had a persistent cough. She coughed so hard she often pulled muscles in her back, causing extreme pain. And her weight problem contributed to debilitating pain in her knees.

“She had stopped going to her adult day program. I was on the phone with her every day to try to get her to come in and see her doctor,” recalls Theisen. “When she said the pain in her knees was so bad she couldn’t climb a flight of stairs out of her basement apartment, I said we really have to act.

“She came into the ER and physical therapists evaluated her. She needed an inpatient stay, but not in the hospital. I got her placed in a subacute rehabilitation facility where she got two hours of physical therapy each day. She did great with it. She stayed for two and a half weeks, and she worked on her diet and started losing weight. When she was discharged, she actually walked into her apartment on her own.”

The episode illustrates how nurse care managers identify dangerous situations before they become life-threatening; help patients navigate the health care system; and maintain close contact with patients to ensure they get the care that will best improve their health.

“Since then,” Theisen says, “she hasn’t come into the ER once.”

The day-to-day activities of a care manager

The work is not glamorous. Theisen shares an 8-foot square windowless office with a pharmacist. The phone rings all the time. There’s a constant buzz from the nearby patient waiting room. And there are regular crisis situations. It’s up to him to cut through the small obstacles that can sometimes keep patients from getting the care they need – organizing rides to appointments, simplifying complex medication regimens, ensuring that visiting nurses understand patients’ individual needs.

“There’s a lot of things that I and the two other nurse care managers can do that take pressure off the physicians and allow them to do their jobs more effectively,” Theisen says. “Even a simple thing like calling to schedule an appointment can be big if you’re not sure how to get a hold of your doctor.”

The Jen Center is a teaching practice, with medical residents caring for patients but ultimately moving on to other assignments. Theisen helps patients adjust to new doctors, and understand that an entire team is providing care.

The center began providing nurse care management for some of its sickest patients under a pilot program with Medicare that began four years ago at Massachusetts General Hospital. Integrated Care Management Program, or iCMP, is one tactic that Partners HealthCare is using across the system to improve care, lower medical costs, and ensure patients have a better experience.

It is part of Partners’ larger Population Health Management (PHM) initiative, in which physicians and other caregivers deliver personal, proactive care to treat patients and keep them healthy. The care management program is now being expanded to more patients at the Jen Center and other practices across Partners.

Knowing each patient helps care managers deliver more personal care 

PHM, and the nurse care management program, helps make care more individual and responsive to patients’ needs. Theisen recalls one patient who fainted in the lobby and was rushed to the ER. He accompanied the emergency team as they stabilized the patient. But when she was placed on a stretcher, the patient’s pocketbook was put in a basket behind her head where she couldn’t see it. And she kept asking for her pocketbook, her anxiety visibly mounting.

“In my notes, it says to make sure that this patient can always see her pocketbook when she is being treated. You have to know little things like that. They have a huge impact. If you don’t respond to them, you’ll spend all your time dealing with them, and you won’t be able to listen to the patients’ lungs, which is why she came here in the first place.”

In morning “huddles” with physicians, social workers, pharmacists and other caregivers, Theisen and the other care managers look at the days’ upcoming appointments and share the information that can make visits easier and more productive.

Another personal touch: speaking with patients to develop a set of achievable goals for the coming months. For instance, he says, a patient might want to improve his or her diet by eating more fruits and vegetables. Supporting those goals – even modest steps – helps patients become more engaged in their care.

Long term, this kind of personalized care helps patients get off the merry-go-round of frequent office and emergency room visits to deal with crises.

“If a patient is really sick, my focus is coordinating her care, making sure all her specialists are communicating with each other, and ensuring they have a solid plan,” says Theisen.

“The best case scenario is that patients stabilize and then you can just check in with them once in a while and make sure that things are going OK.”