Severity Index Drives Patients'
Touch Points with Nurse Navigators

Beyond telephonic outreach, assessment and education, nurse navigators in Bon Secours Health System Advanced Medical Home also manage a case load for face-to-face patient work, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Here, he describes the process of assigning patients to nurse navigators.

Based on our learning experiences with the Geisinger system, it becomes difficult for an RN to handle more than about 150 patients, depending upon the complexity of the patient.

We also give back-line access, and the RNs all have beepers as well. They have the license to give that beeper number to the more complex patients—the frequent flyers who are going to need more attention. Or they can give that access to our colleagues on the managed care side who might be engaged in managing patients with a severe illness. To our case management team in the hospital, it just allows for more bandwidth and clearer communication across the spectrum of care delivery.

In Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination, Fortini shares Bon Secour's case load assignment and management strategies.

Case load is by the physician's decision, Fortini said. For example, Mr. Smith has seven different major active problems. He is on 18 different medications, he is 87 years old and he has a touch of Alzheimer's. That individual needs hand-holding, so that would be the first way to give the patient case management. We also take referrals from the hospital and from our managed care colleagues. We are also using some predictive modeling tools provided to us by insurers to identify patients who need closer following. For more information on Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination, please visit:
http://store.hin.com/product.asp?itemid=4268

How frequently a patient is touched, brought in for face-to-face care or called on the phone depends on the severity index. We use a tool my colleague designed that will calculate a relative readmission risk index based on several sets of criteria: number of medications, length of stay in the hospital, the acuity level of the patient in the hospital and whether or not they are in intensive care unit (ICU) initially, etc. How frequently they are touched depends on how high up the severity index they are.

To order your copy of Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination today, please visit:
http://store.hin.com/product.asp?itemid=4268


P.S. -- You may also be interested in these embedded case management resources: