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Managed care helps nurses guide members through rough waters

Monday February 25, 2013
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Karen Wauchope, RN
Just as fashions come and go, whatís old is new again in healthcare. As healthcare reform discussions focus on patient-centered services, care coordination and patient education and engagement are hallmarks of many managed care insurance plans formed years ago to keep patients healthy and in their homes.

The plans have advanced to the point that New York state is transitioning its Medicaid recipients into a care-management-for-all model.

Managed care allows nurses to function autonomously in helping to solve many membersí health problems and will create additional opportunities for nurses as programs expand to deliver on the stateís declared commitment to high-quality, cost-effective care for its Medicaid population.

"We strive to help our members become empowered, so that they can make the best possible healthcare decisions and become independent in all aspects of their healthcare," said James M. Leone, RN, CCM, a case manager at MetroPlus Health Plan, which offers Medicaid and Medicare managed care plans as part of the New York City Health and Hospitals Corporation. He said helping members navigate the healthcare delivery system and seeing that their needs are met is rewarding. "Ultimately, they are in a better place than where they were at the time of our initial contact," he said.

Leone said sometimes a memberís life is in such chaos that obtaining healthcare is not a priority. To effectively manage a case, he said, a nurse has to build a relationship based on trust and respect, with cultural competence and nonjudgmental communication.

"Helping a client get from the point of being overwhelmed by their life circumstances to the point where they can concentrate on their health needs and actually see an improvement in their overall health can be very challenging," Leone said.

Interventions often take place over time.

"The long-term relationships with patients are very rewarding," said Regina Hawkey, RN, senior vice president of clinical operations for VNSNY CHOICE Health Plans in New York that includes a Medicaid managed long-term care plan and a Medicare Advantage special-needs plan. "You spend time with one patient at a time and use your critical-thinking skills and clinical expertise."


Medeya Machavariani, RN
VNSNY Choice nurse care managers admit members to the plan, follow through with telephone case management, visit at least every six months, and prefill membersí pillboxes or set up other supports to meet their individual goals and achieve their desired quality of life, such as being able to go to the grocery store or church.

Making those little things possible can be tremendously satisfying for nurses.

"You are helping them implement the interventions they need to keep themselves at home," Hawkey said. "Itís up to them to take the ball, but coaching them to do that is so rewarding."

Among VNSNY CHOICE Medicare Advantage Special Needs Plan members, a Commonwealth Fund study reported a 54% reduction in hospital admissions, a 24% decrease in readmissions within 30 days, and a 27% drop in ED visits in 24 months.

Similarly, New Yorkís EmblemHealthís posthospitalization, point-of-care case management team — consisting of a nurse, social worker, pharmacist and two health navigators — also has achieved successes, including a 31% reduction in the 30-day readmission rate in a three-month study. A 2012 article in the American Journal of Managed Care reported the work of the EmblemHealth team, embedded in physician offices, was associated with significant reductions in readmissions, with a total annual savings of $1.2 million, more than enough savings to cover the programís $386,000 cost.


James M. Leone, RN
Marissa Morris-Murray, RN, case manager, clinical administration for the point of care in Brooklyn, credits much of the success to the face-to-face visits she and other case managers have with members, during which they answer medication and diagnosis questions and facilitate follow-up appointments or equipment delivery.

"Any support the members need, we are here," Morris-Murray said. "It stops readmission to the emergency room. Itís the most rewarding position I have held in my entire nursing career. Whether they are assigned or walk in, you build relationships with members."

A nurse for more than 20 years, Morris-Murray is known for going above and beyond for members. For instance, she tracked down a memberís grandson at his employerís location to enlist his help in gaining family support, and the grandfather now receives needed treatments.

EmblemHealth also has launched a new initiative called Neighborhood Care that involves nurses who, along with a social worker and pharmacist, provide health guidance, referral assistance and medication support in storefronts in Harlem and Queens for members who may have difficulty navigating the system.

"It can be challenging," said Karen Wauchope, RN, BSN, CDE, clinical program manager for EmblemHealth Neighborhood Care. "We use all resources available to try to solve problems. We may not solve every problem, but seeing we tried is important to them. They hug us and smile."

MJHS of New York began offering Elderplan in 1985 as one of the first Medicare Social Health Management Organizations in the U.S., focusing on frailer-than-average beneficiaries. HomeFirst, its managed long-term care plan, coordinates the medical and long-term care of chronically ill, dual Medicare/Medicaid beneficiaries.

"Itís very rewarding to help these patients and coordinate services," said Medeya Machavariani, RN, BSN, manager of coordinated care for MJHSís Elderplan/HomeFirst, which provides home attendants, transportation and other support services. "We have members who have been with us for 10 years."

Nurses get to know the planís members well. Nurse assessors visit on admission to the plan, then every six months and as needed to evaluate the memberís needs. Many members lack family or social support. "The care manager becomes their main go-to person," said Machavariani, explaining the care manager may pick up food from a pantry and take it to a member who has nothing to eat.

"We help these people stay in the community," she said. "Every day brings something new."

Debra Anscombe Wood, RN, is a freelance writer.


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