This Week's Challenge: Embedded case managers are at the heart of CDPHP's clinical transformation to a patient-centered medical home, working in physician practices to facilitate medical, behavioral and pharmaceutical services for high-risk patients. We wanted to see the most important roles and responsibilities of the CDPHP nurse case managers.
Click here to view a printable version of the table.
What We Learned:
"We really want to facilitate care of the complex or chronic members. If a physician is working with a patient with multiple chronic conditions and has a strong sense that there’s a need for education and reinforcement of the preventive health guidelines as well as their quality and efficiency matrix, the physician will ask the nurse to be a case manager. This nurse has an office in the practice where they can meet the patient face-to-face and establish a plan of care. Then, if the patient wants to return to see the nurse in the office on a day where they’re not going to see the physician, that is available to them as well. The patient may have a need to come in and get some additional education if they don’t want to do that over the phone because the nurse has many teaching aids available to her that we bring to the practice."
— Charlene Schlude, director of case management at CDPHP.
Missed last week's chart? View "Who's Responsible for Improving Patient Satisfaction?"
Join our Online Communities:
Take this month's e-survey: Reducing Avoidable ER Visits in 2011
Interested in all open surveys? Review them here.
Download new market research: 2011 Benchmarks in the Patient-Centered Medical Home
Read related blog post: 2012 Healthcare ABCs ACOs, Bundled Payments and Case Managers
Share this data with colleagues on:
Excerpted from Case Management in Primary Care: The Business Case for Colocated Care Coordinators, a new resource that 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. 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.