Bon Secours Models Nurse Navigators On Geisinger Embedded Case Managers

Bon Secours Models Nurse Navigators On Geisinger Embedded Case Managers

Bon Secours Health System has put its own spin on the embedded case manager at the center of Geisinger’s Proven Health Navigator model, adding home-grown care improvement tools and retooled workflows to support Bon Secours RN Nurse Navigators.

VP and Chief Clinical Officer Robert Fortini described the rollout of the Bon Secours Clinical Transformation project and the central role of the nurse navigator during an August 10th webinar, Embedded Case Management in the Primary Care Practice: Program Design and Results.

In case you missed this webinar, you still have a chance to watch this highly-rated program.

Register to view the conference today or order your training DVD or CD:

Embedded Case Management in the Primary Care Practice: Program Design and Results

A premier goal of the team-based project is to “provide more care to more people,” Fortini explained, adding that the new system of care is capable of doubling the capacity of a typical practice with a panel of 2,000 patients. Using the principles of division of labor, the project encourages staff members to practice at top of license and puts clinical tasks in the hands of someone most able to help. Often, this will be the RN nurse navigator — a case manager embedded in a physician practice. Bon Secours is also exploring the use of virtual case managers for its remotely located practices.

Support tools include a home-grown online database of community resources that nurse navigators can consult when assisting patients; a patient severity index developed in-house that determines a patient’s likelihood of being readmitted to the hospital; and daily hospital discharge reports generated by registries that fuel follow-up calls from nurse navigators.

An important new workflow is the daily “huddle” — a 5- to 10-minute meeting during which all staff members will review the cycle of patients due to come through the door that day.

While the program is still in its infancy, Fortini expects that the team approach in general and embedded RN case managers in particular will substantially curb 30-day readmissions. He said Bon Secours has also noted improvements in patient cycle times and the hourly rate of completed nurse navigator patient calls, as well as spikes in efficiency, capacity and staff satisfaction.

Fortini shared with webinar participants:

  • The program features, including the embedded case manager's job description and communication strategies;
  • Reimbursement and funding to support the initiative;
  • Indexing patients for severity;
  • Using the embedded case management program in tandem with overall practice redesign for maximum results;
  • Year-one results for the first practice, including the impact on all-cause readmissions; and
  • How the program will factor into Bon Secours' application for CMS's ACO Medicare Shared Savings program.

You'll also get to listen to the question and answer session to hear where to find the financial resources to add RN case managers to primary care practic team, What must be included in the case manager training process, how to introduce the first nurse case manager into a practice, productivity benchmarks for embedded case managers and how to determine patient risk and acuity levels.

Here's what participants said about the live program:

The conference will help us "expand on our success metrics," said Patricia Buzonas, Senior Director, Care Management Solutions, KePRO

We will "use it as a guide for our program," said Anna Winkowski, Manager, Outpatient Enterprise Care Management, Advocate Health Care

You can "attend" this program right in your office and enjoy significant savings — no travel time or hassle; no hotel expenses. It’s so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.

To register for the on-demand re-broadcast of Embedded Case Management in the Primary Care Practice: Program Design and Results or order the training DVD or CD-ROM, please visit:

I hope you find it useful.


Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network