Some might think Lee Herzog, RN, BSN, has a pretty dull job. After all, she spends a large portion of the day on the phone.
But Herzog, a high-risk case manager who supports physicians at Renaissance Health Network in Wayne, Pa., might be at the center of the future of healthcare.
And, as Herzog said, “there is nothing boring about being on the phone every day.”
This has been especially true since Jan. 1, 2012, when Renaissances network of independently owned physician practices inherited 26,000 new patients overnight, said Julianne Cody, RN, MSN, director of clinical program operations.
The patient population increased because the Centers for Medicare & Medicaid Services tapped Renaissance to pilot a new payment model for health organizations that provide services for Medicare, Medicaid and Childrens Health Insurance Program beneficiaries.
Renaissance was among the 32 pioneer Accountable Care Organizations selected. Almost a year and a half later, Renaissance now has more experience than most as an ACO.
Helping Renaissance on this journey are the patient services departments telephonic nurses, who provide education and care-coordination services for patients seen by more than 250 physicians at primary care locations in five counties in southeastern Pennsylvania, Cody said. These nurses keep track of patients with chronic conditions and follow up with individuals discharged from area hospitals.
A lot of PCPs no longer care for their patients in the hospital, so the summary that our nurses give us is invaluable, said Geoffrey M. Burgess, MD, medical director for RHN Chester County and RHN Clinical Nursing Program and Home Health Agency. Our patients receive ongoing care telephonically to insure their well-being. In doing so, the patient is more likely to see the physician in a timely fashion to help prevent ER visits and hospitalizations.
Ultimately, the communication and education the nurses provide patients not only improves care but also keeps healthcare costs at bay, said Burgess, who also is a family practitioner at Gateway Medical Associates in Coatesville, Pa.
While the basic framework for this support system of nurses had been in place for more than a decade by the time CMS noticed it, the influx of Medicare patients introduced a host of challenges for the nursing team once Renaissance became an ACO.
“The patients are a lot sicker, and they have more complex needs coming out of the hospital,” Herzog said. “This is a very fragile population. We are the safety net of these patients so they dont slip through the cracks.”
Many patients have multiple medical issues, require more interventions, and have fewer resources — financially and socially, she said.
“Sometimes they are overwhelmed by the healthcare system itself,” Herzog said.
She noted some people need help making doctor appointments, understanding medication instructions, or recognizing symptoms that require follow-up care.
“You have to be willing to go the extra mile for the patients,” she said. “And that is something we all do very well.”
Cody, who joined Renaissance Health Network two years ago, credits the telephonic nurses for standing strong in the face of tremendous change.
In a little more than a year, the staff has grown from seven nurses to 14, and they have had to learn how to manage patients without always having all their information at the point of contact.
Before Renaissance became a pioneer ACO, its doctors mostly served patients they had known for years. Comprehensive health histories were on file for most.
For the incoming Medicare patients, Cody encouraged the nurses to “go with what they know” as chronic care professionally certified nurses.
The nurses rose to Codys challenge to get the missing pieces of information they needed about their patients.
The result: proprietary software used at the practice level to collect patient data and track performance over time.
Once the data is entered, the medical record then exists for the nurses to access in the course of their telephone work with the patients.
“A lot of what we do is sort of like detective work,” Herzog said.
Using techniques such as motivational interviewing, they ask probing questions to get beneath the surface to “the nitty-gritty of why” patients struggle with specific health issues, she said.
Cody said the goal of the nurses is threefold: improve patient outcomes, contain costs and improve care.
Both Cody and Herzog said the key to the process is collaboration among the nurses, physicians and patients.
“Everyone in the practice is a part of the process of managing the patient population,” Cody said. “It becomes a conversation with the patient, rather than a directive.”
Herzog and her nursing colleagues know they are supported, she said, and they believe in what they are doing.
“I appreciate very much that the people who dont do my job appreciate what we do,” Herzog said.
Susan Hansen is a freelance writer.