Following in the footsteps of Geisinger Health System’s embedded case manager model, Capital District Physicians Health Plan (CDPHP’s) Enhanced Primary Care effort used embedded nurse case managers to move from a provider-centered to a patient-centered model. The model helped to reduce hospital readmissions and emergency room (ER) visits and tighten transitions of care for high-risk patients. Here, Charlene Schlude, RN, CCM, CDPHP director of case management, lists the top 10 aspects of the embedded case management model.
- One registered nurse (RN) covering two Enhanced Primary Care (EPC) practices two times per week.
- High focus on Medicaid and Medicare patients.
- Educational materials funded by the health plan.
- Varied hours, based on practice availability.
- Face-to face introductions with telephonic follow-up.
- Direct documentation in electronic medical records (EMR).
- Focus on self-management, which aligns with Level 3 NCQA requirements.
- Social work case management as needed.
- Pharmacy case management consultation.
- Collaboration with internal quality department for gap closure.
Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination examines two promising pilots in embedded case management: Nurse Navigators working alongside physicians in Bon Secours Health System’s Advanced Medical Home program, and Nurse Case Managers at the heart of CDPHP’s Enhanced Primary Care effort.