Program Profile: Outpatient Care Management

April 1, 2023

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Care management has emerged as a key program in most value-based and population health strategies due to its capacity to improve health outcomes, create a better experience for patients and healthcare providers, and reduce costs. The problem most clinics face is the ability to offer this additional level of care on top of already overwhelmed workloads. The good news? When you joined Ochsner Health Network (OHN), you gained access to industry-leading care management programs like Ochsner’s Outpatient Care Management (OPCM) program.

What is OPCM?

This program – and its team of nurses, social workers and community health workers – was developed to help you manage your most complex patients. Some interventions of the OPCM program include:

Advanced Care Planning & Aging in Place Plans
Complex Care Coordination
Community Resource Referrals & Assistance
Financial
Transportation
Nutrition
Equipment
Housing
Health System Navigation
Chronic Disease Education & Management
Medication Compliance
Lab Compliance
Medication Reconciliation & Education
Self-Management Action Planning

“Population health data and predictive modeling are key to success in this program,” said Philip Oravetz, MD, Ochsner Chief Population Health Officer.

“From identifying patients on your panel who are at a high risk, to gathering and analyzing data and measuring the effectiveness of the program, our OPCM program is producing significant clinical and financial results for patients and physicians.”

Identifying patients who are eligible for OPCM is made easy for you, courtesy of OHN’s expert analytics team. For physicians on Ochsner’s instance of Epic, a best practice advisory (BPA) identifies the patients on your panel who are eligible. OPCM eligibility information is also available in the "Patient Programs" section of the Longitudinal Plan of Care. For Network providers not on EPIC, the Healthy Planet link and your OHN Scorecard provides a similar patient list. On average, we work with patients for about 90 days and will communicate with you and other care specialists as needed.

In addition to being an available clinical resource for your patient’s medical needs, OPCM serves as an important connector to community resources that can help improve their lifestyle and eventually their health. Those services include food assistance, emergency housing, transportation, mental health resources and more. For instance, an elderly patient with limited income may have to choose between getting their prescriptions filled or buying food. The OPCM team works to connect the person to local agencies that provide food assistance, Medicaid and other programs. This allows patients to afford their needed medications, which, in turn, could prevent a visit to an emergency department and a possible hospitalization.

“OPCM's goal is to meet the patient where they are,” said Alison Glendenning-Napoli, MSN, RN-BC, Assistant Vice President of Outpatient Case Management at Ochsner Health System.

“Once the patient elects to enroll in the program, our team does a thorough assessment and, with the patient, we develop a care plan and mutually determined goals that will lead them toward achieving self-care management.”

Program Outcomes

Based on a program evaluation of patients enrolled in 2021, Ochsner’s OPCM program has seen clinically significant results. Almost 1,000 patients were evaluated. In the first 60 days, there was a 63 percent reduction in inpatient care and hospital admissions for the evaluated group. There was also a 52 percent reduction in emergency room visits. After one year, about a quarter of OPCM patients were kept out of the hospital. Nearly three-quarters of these patients were able to maintain control of their HgbA1C and blood pressure. Their body mass index (BMI) also improved.

Patient Story

Just last year, a 52-year-old female patient enrolled in the OPCM program to help manage her diabetes. At the time, her A1C was 9.5. The OPCM team devised a care plan for chronic pain and diabetes. OPCM connected her to a diabetes care specialist who worked with the patient on a care plan. Ten months later, her A1C is down to 7.5. The OPCM team was also able to connect the patient with a smoking cessation program, and the patient has since quit smoking. Our team also helped the patient coordinate physical therapy and specialist visits, order grab bars for the bathroom, and sent resources for counseling and low-income housing. The OPCM program is now working to transition the patient to another level of care management for ongoing follow-ups.

Expanding OPCM to Network Physicians

The program is available across Ochsner Health Network. This year, we plan to provide targeted education to generate patient referrals to the OPCM program. We will begin this education for OHN providers at Slidell Memorial Hospital; Lafayette General Medical Center; Titus Regional Medical Center in Mount Pleasant, Texas. Later in the year, the program will provide the targeted education for our Shreveport, Terrebonne and Morgan City providers.

If you have any questions about Ochsner’s OPCM program, please contact us via email at opcm@ochsner.org or by phone at (504) 842-0802. You can also reach out to your Performance Improvement Coordinator (PIC) with any questions.