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On the rise: Team-based care coordination model takes off

Monday June 17, 2013
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While the patient-centered medical home concept is not new, passage of the Affordable Care Act has elevated the idea of a whole-person orientation to care thatís delivered in a more coordinated way to engaged patients.

"Itís a team-based approach to management of our patients," said Felice Lewaine, RN, medical home care coordinator at two primary care offices with Hunterdon Healthcare in Flemington, N.J. "Iím making sure all of the care is coordinated to help patients manage their health."

The American Academy of Pediatrics coined the term medical home in 1967. Forty years later, the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics and American Osteopathic Association adopted consensus principles of the patient-centered medical home, known as PCMH.

In 2011, the National Committee for Quality Assurance released standards for PCMHs. Two years later, more than 5,500 practices with nearly 27,000 providers have earned that recognition. That number of practices includes 940 in New York and 219 in New Jersey, as of the end of April. In March, NCQA also introduced a Patient-Centered Specialty Practice Recognition program. Nine specialty practices in New York have received the designation. Maimonides Medical Center in Brooklyn received PCMH recognition at five primary care clinics. Hunterdon Healthcare operates 24 recognized sites, and first received the designation in 2011.

Nicole Camporeale, RN, BSN, BS, CTTS, administrative director of clinical and quality management for Hunterdon Healthcare Partners, worked with the health systemís multidisciplinary team of providers, practice managers, administrators and others to understand the standards, roll out the resources and documentation to train employees at the practices, and ensure homes met the standards.

"It was a huge undertaking," Camporeale said. Now, Hunterdon is working on reapplying for the three-year recognition.

New practice model

Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates, a healthcare case management training and consulting practice in Huntington, N.Y., said she expected with passage of the Affordable Care Act in 2010 that nurses would see a continuing expansion of the PCMH model in which care is accessible, continuous, comprehensive, integrated, patient- and family-centered, coordinated, compassionate and culturally effective.

"While this model is a physician-directed one, it will be the nurse case manager who will be central to its success," she said. "Through the identification of those patients most at risk, and then proactively engaging them in their care, outcomes will be improved, dollars will be saved and the rates of patient satisfaction will be increased."

Traditionally, Camporeale said, providers focused on an episode of care. In the PCMH model, the emphasis is on population-based care, with a focus on wellness.

"You try to get patients in more frequently and discuss whole-person care," Camporeale said. "They are looking at individual patients longitudinally and [managing] the entire cohort over time."

Elaine Gunn, RN, BSN, vice president for ambulatory care at Maimonides, said the benefit is for the patient. She described a team approach to patient care and better tracking of diagnostic testing, which results in a more effective visit. "I think the medical home model is more satisfying for the nurses, because you are not doing tasks," Gunn said. "You are getting involved with patients and getting things done that will make real important strides in their healthcare."

A care coordinatorís day

Lewaine, who helps manage high-risk patient populations at two of Hunterdonís primary care offices, cares for patients with diabetes mellitus, heart failure and COPD.

"I work with the clinicians to sort through who needs coordination of care and help navigating the healthcare system," Lewaine said.

She reviews each dayís patients with the primary care provider and assesses what needs to be addressed at that visit. For instance, she checks that patients with diabetes obtain recommended blood tests, eye and foot exams and annual wellness visits.

"The program is based on helping to do preventive care management," she said.

Lewaine might meet with the patient before or after the provider visit. She emphasizes the importance of proper management and works with the patient to set realistic goals, such as walking for 15 minutes a day. "If you set goals too high, the patient wonít be able to achieve them and will get frustrated and abandon them," said Lewaine, who follows up by telephone with patients about once every two weeks to reinforce the plan of care. "You are not going to get through to every single patient, but you can make an impact with some of the patients you are working with," she said.

Lewaine also reaches out to patients who have not been seen recently. She convinced one woman to come in for a wellness visit and a mammogram by addressing her anxiety and verifying insurance would cover it. Lewaine follows up by telephone with patients recently discharged from the hospital to clarify their medication regimens, discuss the importance of adherence to the plan of care and ensure that follow-up appointments have been set. She might arrange transportation to a physician appointment or help a patient enroll in a program to obtain medications. "Itís important to uncover the barriers to follow up," Lewaine said.

Camporeale said care coordinators have picked up on some medication errors and helped patients access resources within the healthcare system or in the community.

"The nurses drive the day-to-day workflow," Camporeale said. "The nurses add so much value to our patients and patient safety."

Role adjustments

Mullahy said nurses wanting to perform PCMH care management need to be creative, independent, possess strong critical thinking and communication skills, and have an ability to work assertively, yet collaboratively, among a diverse group of individuals.

The majority of Hunterdonís care coordinators came from hospital positions, and one came from a specialty practice. Camporeale looked for RNs willing to work in a dynamic environment. "This is a very new role for them to grow and evolve in," Camporeale said. "The nurses have really grabbed onto the concept."

Lewaine, a former cardiac telemetry nurse, learned the basics at a program through Duke University in Durham, N.C.

Hunterdon participates in Horizon Blue Cross Blue Shield of New Jerseyís PCMH Program. All participating primary care practices have access to a new education program to empower nurses to improve care coordination within primary care practices. More than 110 nurses, also known as population care coordinators within medical homes, successfully have completed the 12-week program. This initiative was developed by Horizon, and the nursing schools at Duke and Rutgers University of Newark, N.J., said Carl Rathjen, manager of strategic relationships for Horizon BCBSNJ.

After working as a care coordinator, Lewaine said, she will be eligible to sit for the case management certification exam. Care coordination is a core component of case management, which also includes assessing, planning, implementing, monitoring and evaluating options and services needed to meet clientsí needs.

Mullahy said that while patients are the primary beneficiary of this relationship-based model of care, nurses, physicians and others "feel a heightened sense of a relationship with their patients, a feeling of accountability and responsibility for them and a real sense of belonging to a team whose focus is care."

Lewaine said she finds care coordination rewarding, recalling how she discussed end-of-life options with a patient and family. The patient transitioned to hospice and, ultimately, died at home, which was his desire. "Treating the whole patient, knowing their barriers and breaking down the barriers helps them have a better outcome," Lewaine said. "Itís rewarding and the wave of the future for healthcare to engage these patients in a primary care setting."

Debra Anscombe Wood, RN, is a freelance writer.


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