An emerging group of professionals, most often RNs, work across the care continuum to provide ongoing, proactive help at a lower cost to patients with high risk or complex needs.
Healthcare organizations have strict mandates to reduce readmissions, to divert care from the ER to less-expensive settings when possible, and to address population health.
But who takes on these responsibilities when physicians already have too much on their plates?
"I think that, at least for certain groups or pieces of our population, there is a greater need for hands-on support of the patient above and beyond what physicians are prepared for or educated to do, and what office staff can do in the course of the day," says Nancy Myers, PhD, former vice president of population health strategy at NewHealth Collaborative, an accountable care organization formed by Summa Health—a patient-centered population health management organization based in Akron, Ohio.
Enter care coordinators, also referred to as care managers.
Care coordinators, most often RNs, are emerging as the go-to individuals to work across sites—including hospitals, primary care, specialties, and postacute care—to provide proactive help and continuity to patients who are high-risk or have complex needs beyond a single episode of care.
In the first half of 2016, NewHealth Collaborative avoided 300 ED visits and more than 250 hospital admissions as patients were restabilized in their homes by care coordinators, Myers says. By comparison, 370 ED visits and 300 hospital admissions were avoided in 2015.
NewHealth Collaborative, which today has 90,000 members, began its care coordination initiative in 2012 as an effort to contain costs.
The ACO used EMR and claims data to identify the patients with the most hospitalizations, ER visits, and diagnoses of multiple chronic conditions. "These were our highest-cost and most fragile patients that we could help by intervening and very quickly getting them stabilized," Myers says.
The care team also talked to physicians to find out who they thought would benefit from care coordination. "Claims-based data is old data. By getting out into the offices, we could work with the staff to identify patients who needed extra assistance and get to them early," she says.
Myers hired an all-RN staff that could operate independently and with authority.
Care coordinators must have a broad base of experience across care settings and a breadth of life experience as well to help connect with patients, she says. "While it would be great if they had experience in care management, you just don't find that. We choose RNs who can manage complex medical conditions, understanding that sometimes a social issue is the linchpin. We don't want to be focused on prescribing insulin when what they really need are groceries."
NewHealth Collaborative's care coordinators are embedded in the primary care practices to act as both members of the care team and patient advocates to help develop and carry out a patient's care plan according to his or her life goals.
"The care coordinators marry what the doctor is going to do with what the patient can commit to," Myers says.
The care coordinator stays close to the patient, checking in by phone and in person, until the point where the patient's goals and the medical goals are achieved.
Each of the 13 care coordinators at NewHealth Collaborative has between 100 and 120 open cases. They are funded in part by payer contracts such as the Medicare Shared Savings Program.
"The care coordinators marry what the doctor is going to do with what the patient can commit to."
"We have achieved enough savings to get a portion of payer savings," she says.
The care coordinator program also gets a portion of the stipend that nearly 200 providers pay to be part of the ACO and receive these types of services.
Mercy Health, a Catholic healthcare ministry serving Ohio and Kentucky, embedded its care coordinators into 125 physician practices (including 429 primary care providers) and located care transition coordinators in the acute care facilities.
This began with the Cincinnati and Metro Toledo facilities and recently expanded to Lorain, Youngstown, Lima, and Springfield.
Catherine Follmer, RN, BSN, MBA/HCM, vice president of care continuum at Mercy, and Lisa Cobb, RN, BSN, director of ambulatory care coordinators, have meshed the care transition coordinators and ambulatory care coordination teams to utilize nursing resources and to create a longitudinal care program.
The two programs screen and monitor rising risk and complex patients, including those having joint replacement surgery, to create their panels.
They also take anecdotal referrals from providers, payers, and the ER, which identifies high-frequency users. Hospital care transition coordinators, which follow patients for 30 days, handle approximately 65 patients at a time. After 30 days, the patients are handed off to ambulatory care coordinators, whose present goal is a patient caseload of 150.
"We average roughly 150 patients in 52 skilled nursing facilities in Cincinnati alone," Follmer says. The care transition coordinators follow the skilled nursing facility patients with a goal of efficiently identifying the next lower level of care and decreasing unnecessary lengths of stay, she adds.
The first 24 hours are most critical, according to Follmer.
In one case, an elderly patient wasn't taking her medication properly because she couldn't read the instructions on the bottle. "We only found that out because of the 24-hour call, and we were able to set her up with home care to assist," she says.
Like NewHealth Collaborative, Mercy hires RNs to be care coordinators. "Nurses are able to do the assessment piece that nonclinical, non-licensed individuals aren't able to do," Follmer says.
For example, RNs can assess a COPD patient's breathing over the phone, determine if he or she is using an oxygen tank correctly, and help with breathing techniques.
Cobb searches for RNs with experience in home care, the ICU, or ER, as well as with critical-thinking skills. Candidates should be confident and articulate as well. "Ambulatory care coordinators have to think on their feet and develop relationships with their patients. If they sound the least bit uncertain, the only place that patient is going to go is the ER," she says.
Follmer measures the success of the program by "providing the most appropriate care at the most appropriate time," which can result in decreased readmissions and ER utilization.
For example, the care coordinators can connect a patient with congestive heart failure to a physician's office for a dose of Lasix or a breathing treatment rather than sending the patient to the ER.
"We look at every case that's been readmitted to see if the patient could have been diverted elsewhere," Follmer says. In fact, the care transition coordinator team follows the patient to see what treatment readmitted patients required, and if that care could have been provided elsewhere.
'An optimum level of wellness'
At Sharp Rees-Stealy Medical Centers, a multispecialty medical group of more than 500 physicians at 22 locations in San Diego County, "the goal [of the care coordinator] is to bring the individual to an optimum level of wellness and functional capability," says Janet Appel, RN, MSN, director of population health and informatics.
Sharp Rees-Stealy is highly capitated and receives prepayment for more than 70% of its patient population. The medical group started its care coordination journey five years ago to address the problem of physicians not being able to provide care coordination alone.
Vicki DeBaca, DNS, RN, vice president of health and provider services at Sharp Rees-Stealy, first identified an area in need of care coordination—diabetes, a condition affecting between 10% and 20% of the patient population—and then inventoried the resources at hand.
She found that numerous physician offices and other sites had diabetes care coordination activities in place, but they weren't publicized, centralized, or standardized.
She brought these activities together and gave them structure as a comprehensive professional care coordinator program.
Today, the Sharp Rees-Stealy program has a pool of more than 25 case managers who serve as care coordinators. These managers are RNs with three to five years of acute care experience and know how to navigate the healthcare system. They work with patients to avoid inappropriate admissions and readmissions.
The care coordinators also identify opportunities for care outside hospitals as well as alternative treatments to avoid hospitalization, according to DeBaca.
High-risk or complex-care patients are identified in multiple ways, including:
- Self-enrollment through targeted wellness and education programs, such as smoking cessation, weight loss, and asthma control
- A data team that analyzes key metrics such as medications, diagnoses, ER visits, and hospitalizations
- Physicians, nurses, and other healthcare workers who recommend patients to the program
DeBaca and Appel work together to ensure the proper caseload for each care coordinator, which currently is between 100 and 125 patients.
Metrics to gauge care coordination effectiveness include reductions in admissions and readmissions, timely access to care, medication adherence, lab value normalization, and appropriate use of Sharp Rees-Stealy services.
"We are constantly slicing and dicing the data and working with everything we have to take the appropriate actions for the patient's care plan," Appel says.
Results are shared daily among the staff and leadership to quickly identify opportunities for improvement. "We focus on whether the engagement with the patient has been successful," she says.
Using real-time clinical data, the team can see if engaging a patient and building a relationship helped improve A1C levels, renal function, and eye health—deterioration in any of these areas could cause a patient to be labeled high risk and to receive higher attention.
Appel says one way to justify the cost of case managers is to map that cost against known disease progression costs—such as the cost of care for strokes, blindness, and limb loss—over the lifetime of the patient.
Using technology, including texting and automated vital sign collection, Sharp Rees-Stealy has been able to increase nursing panels. Patients use at-home monitors to transmit their vital signs for asthma, COPD, hypertension, and other chronic conditions directly into a centralized application.
If data is missing, staff at Sharp Rees-Stealy Medical Centers are alerted via a dashboard and can contact the patient to troubleshoot issues such as a disconnected device.
Also, rather than calling patients and waiting for them to call back, care coordinators can use texting to conveniently connect with them and share information.
Technology has helped the organization reach its goal to engage 5% of the population—or nearly 10,000 patients—through care coordination. "That would be hard to do without
creative resources," Appel says.