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.