A pilot program in New York’s Hudson Valley places nurse care managers in primary practices to support patients in danger of falling out of compliance with and participation in treatment plans and wellness initiatives.
The program recognizes that physicians often don’t have time to get to know patients, who may have chronic and multiple conditions and require many services. Care managers step in to understand the support these patients need. The use of care managers is already showing improved results.
The Hudson Valley Initiative is helping to transform primary care practices into medical home models and deploying registered nurse case managers in the practices to coordinate care for those patients most in need because of chronic conditions. As in all medical home models, the EHR is central to care, and health information technology underpins the work, both in providing care and tracking progress.
The early response from physicians shows the effect that nurse case managers can produce through care coordination, said Annette Watson, senior vice president of community transformation for Taconic IPA, a 4,000-member physician group. She is also the immediate past chair of the Commission for Case Manager Certification.
“The first big result from the redesign and care coordination in practices is a pretty significant drop in readmissions,” Watson said. Researchers still have to incorporate payer claims data when it comes in to validate those results. “What we’re seeing is data coming in on the front end at the provider level. But the early results are very promising and moving in the right direction.”
Six case managers work with eight primary care practices at 13 sites in six counties. Three commercial payers in the region also are involved. The pilot began in July 2011 and will run through 2013 to measure whether an open community can achieve improvements in cost, quality and satisfaction.
Each nurse case manager deployed into a practice is a Taconic IPA employee “so the centralized command and control comes from us and not the practice,” she said. In other models, case managers are employees of a provider or a payer, which can lead to confusion when multiple providers and payers are involved with one group of patients.
Multiple EHRs, independent physicians
Unlike other medical home and care coordination models, in which providers may be part of one large integrated healthcare delivery system and use a single electronic health record system, the Hudson Valley pilot is made up of many independent providers in an open community incorporating five different EHR vendors.
“Because open communities are the norm for healthcare delivery, we believe the impact of this pilot will extend beyond the Hudson Valley, and might be a blueprint for others to follow,” Watson said at a recent conference sponsored by the Patient-Centered Primary Care Collaborative, an organization that advocates for medical homes.
In addition to Taconic IPA, the Taconic Health Information Network and Community and MedAllies, a health information service provider, offer technical, consulting and program services to physicians in the Hudson Valley pilot.
EHRs and other IT solutions make possible the care coordination performed by the nurse manager. They may use registries to find patients who haven’t come in for an office visit and other technology tools for outreach to patients.
But the open community model presents challenges. Nurse managers go to more than one practice and work on multiple EHRs. For example, each system may have slightly different capabilities for documentation and information storage or locate them in different places.
“EHRs have standard pieces related to meaningful use now, but even the way they do that is a little bit different,” Watson said. She added, “It’s not been easy to look at the different EHRs and try to standardize.”
Hudson Valley practices use Direct
Hudson Valley practices are also using the secure messaging protocols of the Direct Project for one-to-one information exchange. That has become a solution because “the data coming in goes to the same place in each practice’s EHR,” she said.
Dedicated space at the practice is also important so nurse managers can meet with patients as part of the primary care team but without the constraints of scheduling patients every 15 minutes in an exam room, Watson said. Once a relationship is established, care managers can also communicate with patients by phone or electronically.
Patients who are engaged with the nurse manager may reveal personal situations that prevent them from being able to control their conditions, such as medications too costly for them, or they are too busy caring for aging parents or sick children to tend to their own healthcare needs.
Nurse managers can help steer them toward health goals, such as targeting a low A1C reading for diabetic patients. While the clinical goals may not resonate with the patient, “the patient’s goal may be the same, just described differently,” she said, such as not wanting to have to test blood sugar three times a day. “You meet them where they are,” Watson said.
With the collaborative care model, and if a patient is involved in managing his or her health, physicians can set up protocols of what to do when a condition flares up. For example, a patient with chronic obstructive pulmonary disease may be set up with antibiotics or steroids to take at the first sign of a problem and call the nurse, who can decide if the patient should come into the office. It can prevent them from getting to an acute phase.
“I think that’s why we’re seeing that amount of reduction in emergency room admissions and hospital readmissions," Watson said. "It’s common sense, but a resource that just wasn’t there in the practice.”