How an FQHC Used Caseworkers for Chronic Disease Management

The Nebraska-based Bluestem Health knew whole-person care that accounts for behavioral health and SDOH would be the key to complex chronic disease management, but in the throes of a nationwide workforce shortage, the federally qualified health center (FQHC) wasn’t left with many options.

After nearly five years of focusing on chronic disease management, leaders at Bluestem had determined that traditional provider-led health coaching couldn’t move the needle alone. The organization, which participates in the Centers for Medicare & Medicaid Services (CMS) Chronic Care Model (CCM), first deployed behavioral health strategies to uncover the barriers to patient engagement in care management.

“We know in our practice that if patients are coming to their appointment, they don't want to be non-compliant,” Brad Meyer, Bluestem Health’s CEO, told PatientEngagementHIT in an interview.

“We've always known that patients don't ask their doctors questions, because they're afraid to look dumb or look a certain way during the visit,” Meyer continued. “And so they're able to talk to these behavioral health therapists a little bit more openly, and then the behavioral health therapist can then either relay that information to the provider or work with our certified diabetic educators or our chronic disease nurses to put more emphasis and focus on that patient.”

But as those behavioral therapists began to uncover some of the downstream factors keeping patients from optimal chronic disease management, it became clear Bluestem couldn’t go it alone. Many of the patients enrolled at the FQHC experience multiple social determinants of health, as well as other patient health literacy barriers that keep them from achieving wellness.

And although Meyer and his team knew hiring caseworkers could help with patient navigation and access to social services, Bluestem just didn’t have the resources for building out that workforce.

“Our goal is to wrap that patient around with so many resources that they really have to try to fail. We've always wanted to hire caseworkers to manage these patients,” Meyer explained. “Our diabetic educators and our chronic disease nurses do manage our complex patients, but sometimes patients slip through the cracks or you don't follow up with everybody regularly, only when you're pointed out that they need some assistance.”

But in Bluestem’s service area of Lincoln, Nebraska, there’s a small unemployed population—unemployment rates oscillated from 2 percent to 4 percent from September 2021 to January 2022, according to the US Bureau of Labor Statistics. High employment is admittedly a good problem to have, but it left Bluestem hamstrung for caseworkers who’d stay with the organization for the long haul. Hiring was competitive in that area, Meyer acknowledged, so the organization took a different route: outsourcing.

In partnership with Engooden Health, Bluestem has access to a number of caseworkers who check in with chronically ill patients on a monthly basis and help with healthcare navigation and patient education. These caseworkers aren’t employed by Bluestem, but rather work for Engooden and serve Bluestem and its patients as clients.

Of particular benefit has been the patient education services, Meyer said. When patients know more about their chronic illnesses, including the self-management techniques and potential symptoms and warning signs, they are better able to keep things under control at home and out of high-acuity settings.

Some studies have shown that even just 45 minutes of patient education can improve self-management and, ultimately, clinical outcomes.

“Educating patients on their diseases is a huge piece, which is vastly overlooked in most practices,” Meyer stated. “Because you talk to them about their disease, but that's it. You rely on them after the visit to then remember what you talked about in the appointment and educate themselves later. Or if they have questions, you expect them to call you back.”

With the monthly phone calls, caseworkers are able to reinforce what providers have already discussed during a clinical encounter and also introduce new health information.

That’s paid dividends during the pandemic, Meyer remarked, as many of Bluestem’s complex patients haven’t been able to keep up with public health best practices. Caseworkers have reviewed vaccine guidance, for example, and clarified some facts about the COVID-19 shots, specifically.

Caseworkers have also been instrumental and allaying patient fears of COVID-19 infection that have kept them out of the office since March 2020, a benefit both to the organization revenue cycle and patient care management.

Even beyond patient education and navigation, caseworkers have been instrumental in the wraparound care Meyer and his team originally envisioned. Bluestem already employed a paramedic who would connect with complex patients and check on their food security, their living conditions, and other SDOH that can impact their chronic disease management.

The caseworkers supplement this work, Meyer said, helping to connect patients to social services and add more touchpoints.

“In a lot of practices, once the patient leaves the room, the provider has no idea what's going on with the patient after that,” he noted. “And so now they can see that the care managers are making notes, identifying the progress or shortcomings of that patient's visit.”

The process isn’t perfect, Meyer acknowledged, especially considering the complex populations at hand. There have been some billing snags because Bluestem includes all of its chronic care patients, not just Medicare beneficiaries who can be a part of CCM.

“We don't want to just do the bare minimum to bill Medicare,” Meyer pointed out. “In our organization, we don't start a program unless it's sustainable and then we can grow it throughout our entire organization.”

That level of inclusion was a selling point for Bluestem and its partnership with its caseworkers, but figuring out how to bill CMS and keep out-of-pocket costs down for everyone, Medicare member or not, has been hard.

Getting the ball rolling was the easy part. Most eligible patients had met their deductibles by the time Bluestem was enrolling them in the program, so patients didn’t have to pay out-of-pocket for the monthly phone calls with their caseworkers.

But now that it’s the first few months of a new year, patients are responsible for the $17 copay, and that’s cost-prohibitive for such a complex population. CMS hasn’t yet waived that copay for CCM patients, and although Bluestem might have the option to write off the charge, it doesn’t have that arrangement for chronic care patients with private insurance. Bluestem is currently staring down that problem, considering two possible solutions that aren’t entirely perfect.

“As an organization, we have to figure out for these patients that really need this service, do we just write that deductible off for them every month?” Meyer debated. “Or do we try to educate them on this service is a benefit to them, so that they can see the benefit right now?”

As Bluestem considers its options, Meyer said it hopes to collect hard data proving the utility of the program. The organization has only been using these caseworkers for a few months, so it doesn’t have information about how they’ve lowered emergency department visits or improved outcomes.

But anecdotally, things are looking bright.

“While we can't quantify that, we know that Medicare and Medicaid patients are the biggest utilizers of emergency department services. And a lot of those patients are going to the ER or the ED because they're lonely or they don't have someone to, they can't just call their doctor for some reason and get a question answered,” Meyer concluded.

“And so having these case managers call them every month talking to them about what's going on in their lives for 20 to 30 minutes, you have to think that does have a positive impact on patient outcomes.”