WASHINGTON – Like soldiers inserted into the battle front, anIT-supported pilot program in New York"s Hudson Valley hasembedded in primary practices a network of nurse care managers, whocatch patients who fall off physicians" radar to turn aroundtheir health status. The care managers take the time that physicians often don"thave to get to know patients, who have chronic and multipleconditions and require many services, and to understand the supportthey need. The use of care managers is already showing improvedresults. [See also: Health plans ante $1.5M for Hudson Valley medical homes ] The Hudson Valley Initiative is helping to transform primary care practices into medical homemodels and deploying registered nurse case managers in thepractices to coordinate care for those patients most in needbecause of chronic conditions. |
As in all medical home models, the EHR is central to care, andhealth imformation techcnology underpins the work, both inproviding care and tracking progress. The early response from physicians shows the effect that nurse casemanagers can produce through care coordination, said AnnetteWatson, senior vice president of community transformation forTaconic IPA, a 4,000 member physician group. She is also theimmediate past chair of the Commission for Case ManagerCertification. "The first big result from the re-design and carecoordination in practices is a pretty significant drop inreadmissions," she said.
Researchers still have toincorporate payer claims data when it comes in to validate thoseresults. "What we"re seeing is data coming in on thefront end at the provider level. But the early results are verypromising and moving in the right direction." [See also: Health plans ante $1.5M for Hudson Valley medical homes ] Six case managers work with eight primary care practices at 13sites in six counties. Three commercial payers in the region alsoare involved. The pilot began in July 2011 and will run through2013 to measure whether an open community can achieve improvementsin cost, quality and satisfaction.
Each nurse case manager who is dropped into a practice is a TaconicIPA employee "so the centralized command and control comesfrom us and not the practice," she said. In other models,case managers are employees of a provider or a payer, which canlead to confusion when multiple providers and payers are involvedwith one group of patients. Multiple EHRs, independent physicians Unlike other medical home and care coordination models, in whichproviders may be part of one large integrated healthcare deliverysystem and use a single electronic health record system, the Hudson Valley pilot is made up of many independentproviders in an open community incorporating five different EHRvendors. "Because open communities are the norm for healthcaredelivery, we believe the impact of this pilot will extend beyondthe Hudson Valley, and might be a blueprint for others tofollow," Watson said at a recent conference sponsored by thePatient-Centered Primary Care Collaborative (PCPCC), anorganization that advocates for medical homes. In addition to Taconic IPA, the Taconic Health Information Networkand Community (THINC) and MedAllies, a health information serviceprovider, offer technical, consulting and program services tophysicians in the Hudson Valley pilot.
EHRs and other health IT make possible the care coordinationperformed by the nurse manager. They may use registries to findpatients who haven"t come in for an office visit and othertechnology tools for outreach to patients. But the open community model presents challenges. Nurse managers goto more than one practice and work in multiple EHRs. For example,each system may have slightly different capabilities fordocumentation and information storage or locate them in differentplaces.
"EHRs have standard pieces related to meaningful use now, but even the way they do that is a little bitdifferent," Watson said, adding, "It"s not beeneasy to look at the different EHRs and try to standardize." Hudson Valley practices use Direct Hudson Valley practices are also using the secure messagingprotocols of the Direct Project for one-to-one information exchange. That has become a solutionbecause "the data coming in goes to the same place in eachpractice"s EHR," she said. Dedicated space at the practice is also important so nurse managerscan meet with patients as part of the primary care team but withoutthe constraints of scheduling patients every 15 minutes in an examroom, Watson said. Once a relationship is established, caremanagers can also communicate with patients by phone orelectronically. Patients who are engaged with the nurse manager may reveal personalsituations that prevent them from being able to control theirconditions, such as medications too costly for them, or they aretoo busy caring for aging parents or sick children.
Nurse managers can help steer them towards health goals, such astarget a low A1C reading for diabetic patients. While the clinicalgoals may not resonate with the patient, "the patient"sgoal 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 inmanaging his or her health, physicians can set up protocols of whatto do when a condition flares up. For example, a patient withchronic obstructive pulmonary disease and who is engaged may be setup with antibiotics or steroids to take at the first sign of aproblem and call the nurse, who can decide if the patient shouldcome into the office.
It can prevent them from getting to a reallyacute phase. "I think that"s why we"re seeing that amount ofreduction in emergency room admissions and hospitalreadmissions," Watson said. "It"s common sense, buta resource that just wasn"t there in the practice." [See also: HHS to use IT to help enroll kids in Medicaid, CHIP ].
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