Designing a successful PCMH program involves policy decisions that create new provider and patient expectations, incentives, and infrastructure to support patient-centered care. An integral feature of the CareFirst PCMH program is the development of a care coordination infrastructure at the central, regional, and local level.
Much of the work at the local level is done by registered nurses, such as Michele Brown, who serve as local care coordinators (LCC). Supported by a regional care coordinator and a central data system, Michele is charged with identifying and then actively engaging high-need, high-cost patients by linking patients with their primary care provider and community-based services. Michele’s performance as an LCC is measured by the number, type, and quality of patient and provider interactions.
Preparing for the Day
Each morning, Michele attends a daily huddle convened by Georgette Moderacki, RN, a CareFirst regional care coordinator, with 17 other LCCs based in Georgette’s region. This region spans 52 practices that serve as PCMHs for 27,600 members.
The LCCs live in the communities where they work. According to Jennifer Baldwin, CareFirst Senior Vice President of PCMH, “hiring from the local community is very important. You can’t underestimate the importance of relationships being built on common ground.”
Michele usually attends this huddle from her home. Today, during the daily huddle convened over videoconference, Georgette introduces staff from the central office to discuss goals for “activating” and “closing” care plans. The LCCs, in collaboration with the primary care provider and patient, are responsible for writing the care plan. The care plan is also reviewed through a quality review process to ensure it meets PCMH standards.
Typically during the 20-minute huddle, the LCCs also receive information about resources available to help support their work. Today, the discussion focused on how to improve the use of CareFirst’s intensive care management resources for high-risk patients being discharged from hospitals.
In addition, Georgette frequently describes new reports and data being added to “Searchlight”—a section of the electronic data portal. Today, she describes a data report that identifies the top reasons patients are being admitted to the hospital. One panel of providers, for example, was having a significant amount of behavioral health-related hospitalizations. As a result, a behavioral health coordinator was designated to work specifically with this panel’s patients.
Identifying High-Risk Patients
After the huddle, Michele springs into action. She has 57 active patients and 3 “in development.” Through claims data, patients are given an “illness burden score” that identifies them for care coordination services. In addition, providers also generate referrals. A large part of Michele’s job is identifying and then engaging these patients through regular communication and encounters.
At the initiation of care coordination, the LCC meets face-to-face with each patient at his or her primary care provider’s office. The LCC then meets with the patient about once every three months thereafter. In addition LCCs communicate by phone at least once a week with each patient. All of these encounters are documented within the care plan, which is accessed through the data portal. Additionally, the care plan is updated at each provider visit to reflect patient progress, health status, and updated goals.
Communicating with Her Patients
Most of Michele’s patients are blue-collar workers and their families between 42 and 69 years of age. She makes several calls before heading out in the morning. She phones a primary care provider to discuss switching her patient’s prescriptions to lower-cost brands and requests that the provider waive co-pays for one patient who is struggling to make ends meet.
Michele receives a morning text from one of her longer-term patients, Joe, who provides her with his morning weight and blood glucose. Joe, who prior to being enrolled in the PCMH program was hospitalized six times in the previous year for complications related to congestive heart failure and diabetes, has been successfully treated at home with no hospitalizations in over a year. She replies with an encouraging text.
Meanwhile Michele receives an email from a hospital transition coordinator to discuss a patient’s pending discharge. CareFirst has embedded transition coordinators in area hospitals to alert providers of hospital admissions, do “intakes” and also plan for hospital discharges. She phones the transition coordinator to discuss the need for daily home care and they discuss the need for reconciling the discharge medications with the patient’s previous medication regimen.
Michele then logs into the electronic data portal to check if one of her patients filled a new blood pressure medication after a recent visit to his primary care provider—and he did. She phones the patient to see if he began the prescription and if he is having any side effects. Michele explains, “a lot of my job is monitoring and education.”
She heads out the door and drives to meet a new patient at Dr. Goldman’s office. Dr. Goldman is a solo provider—one of many in CareFirst’s PCMH network. CareFirst primary care providers are charged with banding with their peers to form a panel, which usually consists of between 5 and 15 providers and 3,000–5,000 CareFirst patients. Dr. Goldman shares a panel with nine other primary care providers. Together, they collectively work to improve cost, quality, and satisfaction outcomes for their combined patient populations. If successful, their panel qualifies for performance payments paid as increases on fees for most primary care services.
Engaging with CareFirst Providers
Michele has worked as a LCC at CareFirst since 2011. It hasn’t always been easy to get providers to actively collaborate and refer patients to her, but this has changed. Peer-to-peer outreach has proven to be a successful strategy to engage CareFirst providers in participating in the PCMH program. Because of the mix of financial incentives and the new resources, collaborating with CareFirst providers is getting easier. “They are coming to me and saying, ‘I have a patient that would be very good for the program,’ because they are seeing the results,” says Michele.
She walks into the office and settles into office space provided to her by Dr. Goldman. “It’s critical that patients and the staff see the LCCs as part of the office,” said Michele. Solo providers like Dr. Goldman typically do not have a registered nurse on staff and having Michele in the office several days a week to care for his chronically ill populations has been welcomed. Michele meets with Dr. Goldman and they discuss several CareFirst patients, including a new patient referral. He leaves to bring the new patient into the exam room and introduces Michele as part of his team. The three briefly discuss goals and then the physician leaves and Michele begins her assessment.
Michele does a patient intake assessment and begins by interviewing the patient and taking her history. The patient is 52 years old, a person with long-term diabetes. She has recently quit smoking and is interested in learning how to count carbohydrates and switch to an insulin pump. Michele explains that her role is to help coordinate among the patient’s many doctors and communicate with them through weekly updates—and the patient appears visibly relieved. Michele makes future plans to connect her with a diabetic educator and an endocrinologist as well as a home monitoring program where she can send daily blood glucoses to Michele. They arrange a time to meet next.
Michele heads out the door and makes one more stop at the office of Dr. Schendel, another primary care provider in the panel. Dr. Schendel is the designated “provider representative” or physician champion for Michele’s panel. As the champion, he is responsible for convening the panel quarterly, reviewing data, and discussing issues. Dr. Schendel describes having an LCC to take care of his complex patients as “a relief.” Dr. Schendel remarks, “we all get a benefit that none of us can afford.” Although he has worked with other insurance-based care managers, what makes this program different is the face-to-face time and communication among the provider, the LCC, and the patient.
CareFirst “provider representatives” work closely with the regional care coordinators, like Georgette, and program consultants to discuss issues within the panel, such as performance data trends. Today, Georgette and Diana Mantel, the CareFirst program consultant for this region, join Michele in a meeting with Dr. Schendel to review panel trends. Together they discuss patients that have had readmissions and how resources, including home monitoring programs, might be better utilized.
After the meeting, she leaves for home to begin writing the care plan for her new patient, and have dinner before she begins evening office hours. She offers telephone times between 6–9 PM several nights a week as part of her strategy to connect with her working patients. Michele remarks, “The holistic part of patient care is what makes an RN ideal for this job. We need to assimilate information from multiple providers and settings and develop a care plan and a course of treatment. Nurses are good at taking individual pieces and putting them together, while meeting the needs and desires for a patient.”