That Nurse Saved My LifeThe Critical Role of Nursing Care Coordination and Teamwork in an Accountable Primary Care Delivery Model

Objectivesn �Describe a patient-centered, population-based approach to care delivery

in Primary Care.

n �Identify ingredients for success including outcome and process measurement in a nursing care coordination program for high risk groups.

Problem StatementTHE UNITED STATES HEALTHCARE SYSTEM PERFORMS POORLY IN COMPARISON TO OTHER INDUSTRIALIZED NATIONS:n �More than twice the cost

n �Higher rate of hospital admission for chronic conditions

n �High degree of variability in cost and outcome relationship

n �Rate of cost increase is unsustainable

n �Significant increases in individual out-of-pocket expense

HEALTHCARE INDUSTRY AND POPULATION CHANGES MAKE TRANSFORMATION AN URGENT NEEDn �Aging population, boomer tsunami, increased chronicity

n �Declining number of primary care providers

n �Sickest 10% account for 64% of expenses

n �Social determinants account for the majority of healthcare outcomes

n �Age of accountability and transparency

Essentia Health’s Accountable Care Modeln A better patient experience n Better health across an entire group of patients n Lower overall costs

RN Care Coordinator Rolen Case finding

n Patient enrollment

n Develops Care Plan with the patient

n �Makes sure all clinical needs are met/up-to-date

n �Determines Tier/Care Score (billing and complexity)

n Pre-visit calls and regular contact

n Makes sure specialist visits are kept

n �Patient follow-up after hospital, ER, specialist visits

n Collaborates with physician

n Supports team

Process & Outcome Measures

WHAT DOESN’T THE RN CARE COORDINATOR DO?

n Secretarial, clerical duties

n Appointment scheduling

n Routine patient calls, results reporting

n Pinch hit for clinic staffing gaps

n Refills and phone triage

n IV therapy and treatments

n Work lists, chart scrub, gaps in care

ToolsOne stop shop for resources/information

One stop shop for patient tracking

RN Care Coordinator Role (see right top of poster)

PopulationManagement

Primary Care

RN Care Coordination

1:1 Care

PO

PULATION

MA

NAG

EMENT

CARE COORDINATI

ON

Process tracking is the key to accountability and performancen 754 patients enrolled

n �10 FTE of “dedicated” RN time; 15 RN Care Coordinators 6 are 1.0 FTE; 3 are 0.8 FTE; remainder are 0.2 to 0.6 FTE

n �Goal for caseload is 100 to 125 per FTE. Most RNs are in the process of building their caseload

Results Four designated pilot sites with dedicated, full time Care Coordination

41% reduction in number of ER visits 39% reduction in hospitalizations

Care Coordination ProgramPROGRAM GOAL #1 Improve clinical outcomes of high risk groupsn �Regular contact: continuous caring relationship

n �Pre-visit calls to “package visit” for MD/NP/PA

n �Updates from specialists visits

n �Changes in function/clinical condition

n �Patient’s agenda

n �Self management support, patient education

n �Management of care transitions – after hospital-izations, ER visits, other events

GOAL

1

Care Coordination ProgramPROGRAM GOAL #2Reduce burden of disease for patients and familiesn ��Develop Care Plan with patient and family

• One stop summary of all problems, meds, instruc-tions, plans • �Find out the patient’s personal goals and match

them with the medical plan

n �One trusted person to call when urgent matters arise

n �Advocate and system navigator

GOAL

2

Care Coordination ProgramPROGRAM GOAL #3Reduce the total cost of caren ���Prevent hospitalizations

• Improve patient and family understanding of the plan • Attentive follow-up • Arrange appropriate home supports

n �Prevent unnecessary ER Use • Create a “Primary Care Home” • Emergency plan of care – what to do when…

GOAL

3

Primary Care

Patient Name

Patient Name

Patient Name 6 MONTH PRE-AND POST-ENROLLMENT ANALYSIS