Dartmouth-Hitchcock Nurses Help Bridge Transition, Care Gaps

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Transforming nurses into care and outreach managers helped Dartmouth-Hitchcock to bridge care and coordinate services across transition points, explains its senior medical director Barbara Walters, DO, MBA.

One of the most important things we did was transform the role of the nurse. We changed the nurse from the old-fashioned triage model, in which they played phone tag, trying to reach patients after the fact and discuss lab results, and instead inserted them upstream in the care delivery cycle and made them coaches and healthcare coordinators. We wanted to make sure we had correct diagnoses and problem lists done. Then we would do outreach using the registries where people had gaps in care. We used the nurses to ensure that any diabetics whose hemoglobin A1C’s were out of control had their lab tests done ahead of time. That way, when they had the appointment with the doctor, they were prepared with their lab test in hand and the doctors could have a very cohesive conversation with the patients and make a difference, rather than trying to catch them on the fly when the patients came in for an acute visit. We developed reports to monitor progress and provide feedback to each healthcare team doing this.

Our nurses needed some extra training to do this because many of them had been on the phone for a long time. We needed to rebuild or reactivate the skills that all of them had learned in nursing school about developing care coordination and plans of care. Early on, we partnered with a disease management (DM) vendor who did this on behalf of health plans who helped us with the training and motivational interviewing, developing algorithms for the nurses and designing outreach campaigns.

We quickly discovered that our reach and success rate was about 77 percent of the patients that we called. With these patients, we were able to make a difference: instead of the DM company result that was only about 7 percent, we were up to maybe 17 percent. We decided that we didn’t need to partner with a vendor, and that it worked much better coming from the doctor’s office than it did from the vendor’s perspective, so we embedded these care coordinators in our offices.

The care managers were then focused on managing our most complicated patients, bridging care across transition points and coordinating services across all of the transition points. We gave them success outcomes so that we could understand internally if we were making a difference and devoting resources to the right areas.

Source: Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care

Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care

In Population Health Management Tools for ACOs: Technologies and Tactics to Support Accountable Care, examines the building blocks of population health management that drive improvements in healthcare quality and efficiency in ACOs — while positioning healthcare organizations for core measure improvement and increased reimbursement.

This entry was posted in Care Transitions, Clinical Integration, Disease Management, Motivational Interviewing and tagged , , , . Bookmark the permalink.
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