T2 Design of a RN led Clinical Care Coordinator Program · Generic vs. brand name Preferred vs. non...

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DESIGN OF A RN LED CLINICAL CARE COORDINATOR PROGRAM IN A FEDERALLY QUALIFIED HEALTH CENTER Portia J. Zaire, MSNEd RN-BC Rev DON 10/11/2017 1

Transcript of T2 Design of a RN led Clinical Care Coordinator Program · Generic vs. brand name Preferred vs. non...

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DESIGN OF A RN LED CLINICAL CARE COORDINATOR PROGRAM IN A

FEDERALLY QUALIFIED HEALTH CENTER

Portia J. Zaire, MSNEd RN-BC

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Disclaimer

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I have no vested interest or conflict of interest related to this topic The views in this presentation are based on what we have learned and

gained from our experiences at PrimaryOne Health

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Our History

• 40 + years of Community Health Centers in Columbus

• 20 years  as PrimaryOne Health ‐established in 1997 to sustain community health center model  

o 7 existing health centers merged o Non‐profit 501(c)3o FQHC

• Expanded beyond Columbus in 2014o Dublin (Partnership with Syntero)o Circleville

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Our VisionQuality Healthcare for All.

Our MissionThe mission of PrimaryOne Health is to provide access to services that improve the health status of families including people experiencing financial, social, or cultural barriers to healthcare.Core ValuesRespect • Quality • Compassion • Service

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Our Organization

11 Health Center locations

10 –Franklin County 1 –Pickaway County

Corporate Headquarters

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PrimaryOne Health Locations

1180 East Main 2300 West Broad 3433 Agler Road

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PrimaryOne Health Locations

1791 Alum Creek Dr.240 Parsons Avenue

600 N. Pickaway St. Circleville, Oh

1905 Parsons Avenue

299 Cramer Creek Ct., Dublin, Oh

595 Van Buren Dr.

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PrimaryOne Health

325 Employees

55 Providers• 19 Physicians• 24 Nurse Practitioners• 7 Dentists• 5 Optometrists 

12 Person Board• 7 Patient Board Members • 5 Non‐Patient Board 

Members

12 Voting Directors

Our Staff Our Board

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Our Services

Internal Medicine Family PracticeBehavioral HealthObstetrics/GynecologyPediatricDentalVision Cardiology*Physical TherapyDermatology*

*OSU Collaboration

Healthcare for theHomeless

Nutrition Services

Pharmacy Services

Patient Education

Care Coordination and Transition Management

Transportation

Translation/Interpreters

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2017 Statistics

As of July 2017 PATIENT VISITS 91,073 UNDUPLICATED PATIENTS 40,000+

Payer Mix: Uninsured 30% * Medicaid 48.7% Medicare 10% Private Insurance 10.7% Homeless .5%

* Uninsured Pregnant Women: 40-70% across our locations * Dental - 58% of patients lack insurance

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Care Coordination and Transition Management 11

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What is Care Coordination and Transition Management?

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Over 40 definitions Deliberate organization of patient care activities between 2 or more

participants (including patients). Basically, care tasks that we normally would do for a patient in a

typical exchange or as a result of an encounter with the healthcare system

Gift wrapping all the nuances into one box Transition Management involves organization of patient care between

levels of care

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What Does This Look Like?

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Referral management Closing care gaps Population health management Pre-visit planning Care team planning/meetings Transition management Education Community agency mapping Home health coordination Care planning Putting the pieces of care together for the patient

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Roles and Functions

Care Coordinator Case Manager Care Manager Nurse Navigator Care Navigator Community Health Worker Discharge Planner Transitional Care Manager

Hospitals Provider offices Insurance companies Skilled nursing facilities Mental health facilities Specialty and surgery centers Home Health Companies

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Titles Locations

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Why Care Coordination?

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Healthcare climate is changing Affordable care act (citizens have to be in charge of their healthcare costs). Payment changes for poor quality care and readmissions CPC and CPC+ (quality and efficiency measures)

Patients are changing Living longer with chronic diseases More options for healthcare Access to information has increased Expectations are rising

Healthcare costs Smallest group of patients cost the most amount of money High utilization, high cost

PCMH Cornerstone of medical home is coordinating care Reducing care fragmentation

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Break it Down

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High cost-high utilization Generic vs. brand name Preferred vs. non preferred drug Duplicate testing/procedures

Treatment of diabetic patients in hospital Study published in 2003 Houston, TX 167 admissions for DKA Average age was 40 49% African American 32% Hispanic American 18% White Average cost per patient $10,876-$11,024 ($7,470 due to noncompliance/nonadherence)

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RN in Care Coordinator Role

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RNs are versatile Work in many different areas Varied areas of specialty Formal education that covers patho phys, A&P, nutrition, coaching and counseling,

therapeutic communication, patient education, patient advocacy, etc.

Nursing is consistently listed as most trusted profession Knowledge, skills and attitudes needed to apply care coordination principles Patient advocate Experienced in creating and reviewing individualized care planning Work at top of license

Able to practice nursing independently

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Definition of Nursing

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According to the American Nurses Association…… “Nursing is the protection, promotion, and optimization of health and

abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.”

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Knowledge, Skills and Attitudes (KSAs)

Identifying patterns of human responses to actual or potential health programs

Executing a nursing regimen Assessing health status Providing health counseling and health

teaching Executing treatment regimen Teaching, administering, supervision,

delegating and evaluating nursing practice

Communicating patient values and preferences Understanding principles of change management Using communication skills (assertiveness, negotiation,

conflict resolution) Using evidence-based care planning Flexible and committed to patient/family Identifying support for patient Acting with honesty and integrity in relationships Describing motivational techniques Understandings SMART goals Seeing patient as partner Identifying related determinants of health for patient

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Ohio Board of Nursing American Academy of Ambulatory Care Nurses (AAACN)

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Characteristics of Ambulatory Care Nursing

Nurse acts as consultant to patient/family Nurses are more autonomous/independent Requires developed critical thinking and assessment skills Facilitates access to all levels of care Focuses on wellness, health promotion and disease prevention Manages multiple, often conflicting priorities Values patient advocacy Provides holistic nursing care Provides patient teaching Facilitates care coordination Conducts time-limited, episodic, nurse-patient encounters Establishes long term relationships Conducts case management activities

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Our Journey 21

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RNs in Ambulatory Care

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Have always employed RNs in our centers

Role was not delineated

Role confusion among the RNs, MAs and LPNs

Care Coordinator role was introduced in 2013

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RN Care Coordination

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Introduced and piloted with 3 sites (3 Registered Nurses)

Focus originally on diabetics and patients receiving anticoagulation

Basic training provided

Instituted monthly meetings for Care Coordinators

Extended to each of our larger 6 sites

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Transition

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Period of turnover with RNs Some left company Some promoted

Major concerns Reporting structure Salary Lack of role delineation Lack of standardization and training

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Transition

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Hiring freeze Review of literature for best practices in care coordination

Training and education Program execution Desired qualifications of staff Model of care coordination

Synthesized data to restructure program

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Program Restructuring

• Employment/personnel Pay Recruitment/retention RN qualifications Reporting structure

• Training/Education of RN Onboarding Role specific training Ongoing and continuing

education

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Areas to Address Areas to Address

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Program Restructuring

• Workload Patient selection and

identification Site assignments Population focus

• Communication Inter-professional communication Patient communication Team communication

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Areas to Address Areas to Address

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Final Plan for Restructure

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Hired less RNs with higher salary Changed reporting structure to nursing Purchased and implemented EBP training specific to care coordination Standardized onboarding and training set in place Developed written workflows for role and care tasks Established audit and review processes Initiated streamlined tracking system for referred patients Introduced teamwork model and redefined communication

expectations

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Clinical Care Coordination

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Program re-introduced Feb 2016 with single existing RN New RNs started in March 2016

Completed 6 weeks of intense training Total of 4 RNs for 9 sites

3 RNs with 2 sites each 1RN with 3 sites No specialty care coordinators at this time

Training Evidence-based training provided by American Academy of Ambulatory Care Nursing Disease specific training Soft skills training Multi-specialty training Interdisciplinary shadow

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Clinical Care Coordination

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Teamwork Expectations set at hire and formation of team Single most important element in successful program implementation Frequent meetings Weekly huddles via Skype Monthly meetings in person Email Text messaging

Coverage expectations and guidelines Servant leadership

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Accomplishments

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2016 2017

#Referrals 656 746

#Visits 1188 1701

#DM patients referred 530 646

#HTN patients referred 41 20

#COPD patients referred 20 9

#polypharmacy patients referred 10 6

%patients referred (FM/IM) 2% 1%

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Patient Impact

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RN Led Clinical Care Coordination has increased trust in health care High risk patients now have 1 point of contact for all of their needs Patients get their needs met quicker, more efficiently and thoroughly Patients are receiving personalized and validated health information

to aid in self management Patients are coached through their change stages using validated tools

such as Motivational Interviewing and teach back methods

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Patient Satisfaction

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“She has helped me to understand why my health is so bad” “She helped me get my medications changed to medications that would

work for me” “Since she has helped me I am confident that I can care for myself” “I would give her 10s all across because she listens and gives me answers” “I really appreciate her, she is my favorite person there” “She is very helpful and knows so much more than other people” “I rely on her to help me with everything” “She was very helpful, I really appreciate her” “She is great with helping us”

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And More Satisfied Patients…

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“She is showing me how to take care of my diet, exercise and my medicine”

“She is really interested in me and my health” “My nurse is superb and I have recommended her to everyone” “She is amazing and so is PrimaryOne Health”

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Future Endeavors

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Chronic Care Management RN led program Reimbursement for services currently providing Revenue generating

Transitional Care Management RN led program Reimbursement for services currently providing Revenue generating

Anticoagulation Management Interdisciplinary approach Strict management of patients on any time of anticoagulation CCC model RN led program Management (non-face-to-face is reimbursable under CCM) 2 RNs completed certification course summer 2017

Certified Diabetes Educator Services 1 RN actively enrolled in program 2 RNs preparing to enroll in program

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References

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American Academy Academy of Ambulatory Care Nursing. (2017). Scope and standards of practice for professional ambulatory care nursing (9th ed.). C. Murray (Ed.). Pitman, NJ: Author.

American Nurses Association (ANA). (2012). Care coordination and registered nurses’ essential role: Position statement. Retrieved from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Care-Coordination-and-Registered-Nurses Essential-Role.html

Berry, L.L., Rock, B.L., Smith Houskamp, B., Brueggeman, J., Tucker, L. (2013). Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedins, 88(2), 184-194. http://dx.doi.org/10.1016/j.mayocp.2012.10.016

Care coordination: the game changer: how nursing is revolutionizing quality care. (2014).Silver Spring, Maryland: American Nurses Association:nursesbook.org.

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing : leading change, advancing health. Washington, D.C. :National Academies Press,

Haas, S.A., Swan, B. A., Haynes, T. (2014). Care Coordination and Transition Management Core Curriculum (reprint). Pitman, NJ: Janetti Publications Inc.

Reducing Care Fragmentation: A toolkit for coordinating care.(Prepared by Group Health’s MacColl Institute for Healthcare Innovation, supported by the commonwealth fund), April 2011

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Questions

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Portia J. Zaire, MSNEd [email protected]@gmail.com614-859-1884

Connect with me38

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