Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

On the road to practice and clinical transformation, early adopters are testing a retooled care delivery model that capitalizes on case managers embedded in the primary care practice. In just a short time, these colocated care managers are generating promising ROI as much as 2:1 in one early pilot and impressive spikes in practice efficiency, volume and quality of care.

Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination examines two parallel East Coast efforts in embedded case management: Nurse Navigators in Bon Secours Health System's Advanced Medical Home program, and Nurse Case Managers at the heart of CDPHP's Enhanced Primary Care effort.

Case Managers in the Primary Care Practice Following in the footsteps of Geisinger Health System's embedded case manager model, both initiatives are driven by the same core desire to move from a provider-centered to a patient-centered model. This restructuring aims to utilize all staff members at the highest levels of licensure, reduces waste and improves care quality and access for patients and health plan members. Both organizations say the model is helping to reduce hospital readmissions and ER visits and tighten transitions of care for high-risk patients.

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The 50-page Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination documents development and rollout strategies and results from two similarly sized pilots of embedded case management:

Bon Secours Health System Advanced Medical Home: Robert Fortini, Bon Secours VP and chief clinical officer, describes how RN nurse navigators are helping to transform care during a three-phase Advanced Medical Home program. Implementing retooled workflows, nurse-driven protocols and selection of homegrown tools and indices, Bon Secours hopes to effectively double the capacity of its 350 physicians in 80 Virginia locations while improving the health of its patient population.

CDPHP Enhanced Primary Care: New York-based CDPHP has enlisted private practices to pilot its two-part Enhanced Primary Care program. Lisa Sasko, MA, MBA, CDPHP director of clinical transformation, and Charlene Schlude, CDPHP director of case management, share details on a pilot that encompasses both payment and practice reform. Ms. Sasko covers new reimbursement strategies, PMPM savings and quality gains generated by the effort, while Ms. Schlude details the philosophy, framework and practicalities of embedded case management, including schedules, case loads, hiring, program costs and lessons learned.

Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination also provides details on:

  • Three key reasons to pursue clinical transformation;
  • Applying division of labor principles to a physician practice;
  • Readying a practice to receive case managers;
  • Guidelines for embedded case manager skills, selection, funding, case loads and job responsibilities;
  • Target populations and member stratification strategies;
  • Contributions of pharmacists to CDPHP's Enhanced Primary Care effort;
  • Benefits of home-based telemonitoring for patients with end-stage renal disease (ESRD);
  • Guidelines for integration of primary and behavioral health in a physician practice;
  • Lessons learned on practice selection and staff selection for embedded case manager pilots;
  • Value-added services available to nurse case managers to support home visits and home case management;
  • and much more.

PLUS the Q&A chapter answers more than 30 questions on the patient-centered activities of these two organizations.

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