RN Clinical Care Coordinators: Rocks in Granite State’s Newest Accountable Care Program

Tuesday, May 29th, 2012
This post was written by Patricia Donovan

In what is believed to be the largest accountable care program in New Hampshire, the Granite Health Network (GHN) and Cigna are launching a collaborative accountable care initiative to expand patient access to healthcare, improve care coordination, and chip away at escalating healthcare spend associated with high risk, high utilization patients.

To benefit from this collaboration are more than 23,000 individuals covered by a Cigna health plan who receive care from more than 900 healthcare professionals across GHN’s five independent charitable healthcare organizations. Patients who need help managing a chronic condition such as diabetes or heart disease will be among the first to reap the new program’s benefits.

The new accountable care initiative will receive solid support from a team of registered nurse clinical care coordinators who will be embedded in care sites, according to a Cigna press release:

Critical to the program’s benefits are registered nurses, employed by each of the five GHN healthcare organizations, who serve as clinical care coordinators and are integrated into the care delivery team to help patients with chronic conditions or other health challenges navigate their healthcare system. The care coordinators will enhance care by using patient-specific data provided by Cigna to identify patients being discharged from the hospital who might be at risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill. The care coordinators will contact these individuals to help them get the follow-up care or screenings they need, identify any issues related to medications and help prevent chronic conditions from worsening.

The care coordinators will also help patients schedule appointments, provide health education and refer patients to Cigna’s clinical programs, such as disease management programs for diabetes, heart disease and other conditions; and lifestyle management programs, such as programs for tobacco cessation, weight management and stress management. This initiative is unique in using data and analytics at the health system level to focus healthcare professionals more fully on engaging patients to improve the coordination of their care as well as develop best practice clinical initiatives across the GHN member health systems.

Cigna will compensate GHN for medical and care coordination services it provides. Additionally, GHN organizations may be eligible for financial incentives if they meet specified clinical and financial targets, Cigna said.

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One Response to “RN Clinical Care Coordinators: Rocks in Granite State’s Newest Accountable Care Program”

  1. carey says:

    Very interesting, thanks. I really like the idea of having RN’s — who already are so central to the success of any care interaction — be central to care coordination within a new ACO model particularly geared towards patients with chronic conditions. How will this change their already integral role as care provider in the clinic? And how will other providers also need to shift their role to implement this new new care design? I look forward to hearing your thoughts.