Care coordinators vital to PCMH success

Care coordinators essential to PCMH successPhoto used with permission from

Thousands of primary care practices have taken the plunge and become recognized as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). Many have found the process of transformation to be a challenging but rewarding experience.

Among the innovations practices employ, there is a strong focus on:

  • patient management during transitions of care to decrease readmission;
  • scheduled, proactive outreach to high-risk patients; and
  • initiatives that support patient self-management of chronic diseases.

To facilitate these “pillars” in the medical home, PCMHs have hired care coordinators to create new workflows that integrate these activities into the team approach. This supports collaboration with already overburdened providers, and encourages medical assistants to contribute in a more valuable way to the patient visit.

I am the director for care coordination at one such practice, Vanguard Medical Group (VMG) of Verona, N.J. We have four care coordinators across three locations, which has helped the practice improve outcomes and maintain the NCQA PCMH recognition it first earned in 2009. We leverage tools such as healthcare communication networks and the practice’s EHR to help the care team — made up of physicians, mid-level providers, medical assistants and a diabetes educator — manage patients with complex needs, design standardized treatment plans across the sites, and encourage patient engagement. 

Among other benefits, this process has produced decreased utilization rates. One of our local facilities has a 25 percent lower hospital readmission rate than our local peer practices. As data exchange and care quality requirements like these increase, technology-equipped care coordinators will become more integral to achieving success in PCMH programs.

PCMH becoming the norm
As of May 2013 there were 141 practices in New Jersey, including VMG, that had earned the NCQA Patient-Centered Medical Home distinction, which recognizes primary care practices that demonstrate a team-based model of care, increased access for patients, and implement the concept that the PCP is a “quarterback” who collaborates with specialists to coordinate care across the continuum.

Becoming a medical home is growing in popularity in the state as more practices receive financial incentives from major health insurers for following PCMH program guidelines. Those incentives are crucial because they help compensate practices for the enhanced cost created by care coordination activities, which are required to comply with the NCQA rules. In February 2013, a health insurer who contracts with us reported that statewide more than 200,000 of its members were served by a practice participating in its PCMH program.

Technology aiding care coordinators
Increased clinical data demands from payers -- but also from hospitals and other providers in VMG's integrated “medical neighborhood” who benefit from bi-directional information flow -- are driving the growth of care coordinators. Care coordinators are at the hub of this data exchange, which is greatly aided by health information technology.

Vanguard is connected to NaviNet, a nationwide communications network, where we submit and receive real-time claims, coverage eligibility and preauthorization requests from nearly all our payers, including Medicare. In addition, we transmit clinical quality data electronically to payers who participate in our PCMH program. The efficiency of accessing multiple payers through one network enhances the productivity of the billing staff, care coordination and the front-desk team. 

Likewise, health plans assist Vanguard by sending data regarding high-risk patient activity with monthly or quarterly updates from across the communications network. For further analysis, our care coordinators aggregate the payer information in an internal database of patients, and reassess their risk score using our own rigorous algorithm. This allows us to standardize high-risk management across all payers, and in all VMG sites.

We also receive a daily census of our admitted patients from two area hospitals. One of those hospitals automatically sends emergency department, history and physical, consult and discharge reports for each transition. Currently, those reports are faxed, and the medical assistants on the care coordination teams ensure timely transfer of data to tracking spreadsheets. Creating consistent workflows using technology is key to analyzing effectiveness. For example, each quarter, we audit the inpatient spreadsheet and share results with hospital C-level executives and their team to pinpoint records we haven’t received and improve the automatic flow of electronic information into the practice. This partnership supports decreased utilization and improves our ability to do successful real-time care management.

Standardized medical record
At VMG, care coordinators help standardize and code visit notes in such a way that allows us to run reports on types of encounters such as inpatient discharge, emergency department visits, triage calls, population management and high-risk outreach. This visit note can be attached to a message using the EHR internal email system, which allows the care team to communicate about patients immediately and efficiently. Integrated care coordination visit notes support consistency in the treatment plan and encourage collaboration. It also helps providers by reinforcing their goals and treatment options with the patient and focuses attention on how the patient can be more involved in their own care.

In this regard, technology, again, assists the care coordinators. Our EHR system offers robust document management features, so providers can quickly find and share the information they need. For patients with chronic illnesses, we have developed an “action plan” and are piloting the initial template with high-risk diabetics. The action plan is designed to address traditional diabetic milestones such as lab data and blood sugar testing, but also addresses patient goal setting, motivation to change and evidence-based websites that help patients understand their condition. The action plan is documented as part of the provider visit, can be tracked through reports in the EHR, and is given to the patient in hard copy after the visit. 

An evolving role
Care coordinators have become a valued member of the care team in PCMH practices.  Our roles may continue to expand as health insurers unveil new and more demanding value-based payment contracts that require an even closer examination and management of patient populations. Efficient and consistent processes that use technology to streamline activities are essential in keeping the care coordination function viable and cost-effective.

In the coming years, care coordinators will likely require not only clinical expertise, but also greater database and analytics skills. By investing in flexible technology that can make the data collection, exchange and analysis more customized to current and future practice needs, the care coordinator’s role will continue to fuel PCMH transformation, and improve patient outcomes. 

Janet Duni, RN, BSN, CCM, MPA, is director of care coordination at Vanguard Medical Group in Verona, N.J.

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