Posts Tagged ‘embedded case managers’

8 Effective PCMH Tools to Protect the Medical Home Investment

March 19th, 2015 by Cheryl Miller

The patient-centered medical home (PCMH) model is one of the top five investments in 2015, according to Accenture’s recent analysis of government-sponsored State Health Innovation Plans. Researchers from Accenture found that states are investing in PCMHs in order to strengthen primary care integration with specialists and community health workers. Most will also integrate physical and behavioral care.

Embedding care coordinators in physician offices so they can work with case managers is one way to achieve this integration, according to respondents to the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN). We asked survey respondents what other tools they felt were most effective in implementing the medical home. Following are their responses:

  • Electronic communications that include actionable data and access to patients to initiate the change, and a focus on minimal hassle to physician office.
  • The NCQA PCMH tool.
  • Pre-visit planning and ‘huddles.’
  • Patient registries.
  • Monitoring. We fundamentally changed how we operate daily and monitor change. We incorporated our goal measures into the very fabric of what we do.
  • Using templates in electronic medical records (EMRs) for pre-visit planning and coordination of relevant visits.
  • Home care nurse management system.
  • Patient-centered scheduling.

Source: 2014 Healthcare Benchmarks: The Patient-Centered Medical Home

2014 Healthcare Benchmarks: The Patient-Centered Medical Home is the Healthcare Intelligence Network’s in-depth analysis of medical home adoption, tools, technologies, challenges, benefits and outcomes. Based on HIN’s PCMH survey administered in February 2014, this resource takes the industry’s pulse on patient-centered activity. Now in its seventh year, it is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

12 Core Competencies for the Hybrid Embedded RN Care Manager

December 30th, 2014 by Cheryl Miller

Core competencies for a registered nurse (RN) are different than those for an RN care manager, says Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. When Sentara officially converted to a hybrid embedded case management model, RN care managers’ job descriptions had to be rewritten; to be successful in this new model, they didn’t necessarily have to have care management experience; instead, having a strong clinical background and experience doing patient assessments were more important.

To get RN care management away from the embedded telephonic model, we had to rewrite the job descriptions, and if you’re going to rewrite job descriptions, have a new position. This is different work.

We found out people will hear it, but until they go through it, until they feel it, they’re all for it until it actually happens. If I were to do this again, I would make everybody reapply for their job because this requires a certain type of individual. These people need to be able to engage patients for a long-term relationship. They have to know how to work with hospital-based caregivers, home health, life care and not just within our own healthcare system.

We established core competencies. Core competencies for an RN care manager are different than those for an RN. We have an ambulatory-based RN. We were looking for people that didn’t necessarily have previous care management experience, but who had experience doing patient assessments. They also had to have a strong clinical background.

Following are 10 more core competencies for the hybrid embedded RN care manager:

  • Job descriptions: BSN requirement
  • Maintain patient lists by populations
  • Accept assignments
  • Meet expectations
  • Send patient letter from primary care physician (PCP)
  • Engage patients
  • Send contact letter, brochure
  • Standardize work flow
  • Use SMG, Optima (Health Plan), and clinically integrated network (CIN) electronic medical record (EMR)
  • Hold meetings with home health and inpatient care coordinators
  • Complete education/training
  • Achieve specialty certification

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

6 Ways to Overcome Pushback to Embedded Case Management

September 11th, 2014 by Cheryl Miller

Change always incites pushback, and when Sentara Medical Group went from an embedded case management program to a hybrid approach, patient and provider pushback prevailed, recalls Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group. Among the six ways Sentara overcame resistance was to establish and maintain patient-centered relationships, by conducting comprehensive initial and ongoing assessments with patients, and developing plans of care and coaching education for both patients and their caregivers.

  • We maintained patient lists by populations within our electronic platforms. We came up with a standardized screen or view for all care managers. There was a lot of pushback against standardization but the key is standardizing the workflows. Should someone go out on family and medical leave, you can transfer your patient list. It all looks the same.
  • They were given and are still given assignments. We set expectations, which is critical. We send patient letters from the primary care physician (PCP) on behalf of your primary care provider that state we have this resource to help you should you be admitted to the hospital. We’re very focused on engaging patients. We have a brochure, and each care manager has a bio form that talks about their background.
  • We built workflow within the practices, within care management and within our electronic platform. We had issues: Optima, our health plan, is on a different EMR, as are the practices within our clinically integrated network. Unfortunately, the ambulatory-based care managers, the medical group care managers have to move between these two other platforms as well as our platform.
  • We held many meetings with home health and in-patient care coordination. Putting a face to a name is very helpful, as is lots of education and training. We had to do the electronic medical record (EMR) training. We discussed how to engage and motivate patients. What’s motivational interviewing? We have a requirement that within two years case managers are required to have their specialty certification.
  • We defined the care manager’s role. The main piece is to establish and maintain patient-centered relationships. They conduct comprehensive initial assessments and ongoing assessments, identify ongoing needs of the patients and possibly their caregiver, developing care plans and then providing coaching support to the patient, caregivers, and family members.
  • We managed resources such as transportation. We contract with the taxi service for our few patients that don’t drive but need to get to their appointments or to keep them out of the EDs in the hospitals. They manage transitions of care. They conduct advanced care planning.

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

Q&A: Embedded Workplaces, Home Visits Emerging Trends for Case Managers

March 28th, 2013 by Cheryl Miller

As the healthcare industry continues to evolve in the wake of ACA reforms, case managers are taking on more standardized collaborative approaches to care coordination and its changing delivery systems.

Prior to her presentation during a February webinar on The Role of Case Managers in Emerging Care Delivery Models, we talked with Teresa Treiger, RN-BC, MA, CHCQM-CM/TOC, CCM, president, Ascent Care Management, about emerging trends in case management, including embedding case managers at large employer work sites, and the proliferation of home visits.

HIN: What advice do you have for case managers going into embedded workplaces and what are some of the obstacles those already embedded have encountered?

(Teresa Treiger): One of the most important things to keep in mind is that you’re walking into someone else’s territory, where dynamics and relationships are already established. There’s a trust amongst the staff that’s already there.

As a case manager, you need to survey the landscape to figure out how people relate to each other, and then just use good business etiquette, for lack of a better way of expressing it. It doesn’t mean that you change your case management process. Absolutely not. We know case management. But how we relate to the people around us is probably the number one thing.

You will be faced with a situation, without a doubt, that has challenged other people. It could be a difficult patient or a patient that’s labeled as being difficult. And that is where you are going to prove your worth, by leveraging the skills that you have to find out what really is the issue or issues going on, and finding ways of addressing them. You might not be able to solve all of them. But you can address them in a professional way, helping that individual to resolve something, to get a service they haven’t been able to, maybe obtain some equipment or get a community resource hooked up with them. That’s when you start to develop your own currency of trust with the people that you work with, and that’s what’s going to get you firmly ensconced as a part of the team.

HIN: Will we see more case managers called upon to do home based care?

(Teresa Treiger): I think so, for a couple of different reasons. There are already community-based companies that do home care. And (case managers) may be part of or leading the team of lay care workers for these companies, (acting as) main points of contact to their individuals, at least when the client, or a family member has the resources to engage a company like this. These are often for-profit companies that will step in and provide a network of community-based individuals who come in and help for those who don’t qualify for other services.

There’s also the Visiting Nurse Associations (VNAs.) I’m not entirely sure what they’re going to be doing with case managers, but there is definitely an opportunity for them.

Accountable care organizations (ACOs) will also be using case managers that are assigned into a practice, or a group. It doesn’t matter where the patients of that group are, in the hospital, in the skilled nurse facility, at home. That case manager is part of that individual’s team. If the individual is at home, and hopefully most of them will be, they’re going to be helped there. It’s very resource intensive, because not only is the case manager not in the office, where other people may need him or her, there’s travel time, and the issues that go with that. And so while it sounds like a really great plan, the reality is there’s a cost involved, of both money and human resource.

The bottom line is that the Affordable Care Act (ACA) already highlighted community-based care. So the opportunities will be and continue to be out there for case managers to be more involved with their communities at a community level.