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.