Using A Nursing Coordination of Care Model

Using A Nursing Coordination Of Care Model To Create A “Temporary Medical Home”

Gelb Consulting, An Endeavor Management Company 2700 Post Oak Blvd P + 281.759.3600 Suite 1400 F + 281.759.3607 Houston, Texas 770567 www.endeavormgmt.com/healthcare


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Introduction and Overview Academic Medical Centers have unique and specific issues to address in regard to the coordination of care for patients traveling from out of state and out of the country. Many coordination of care models have been tested with varying results. This specific care coordination model addresses the needs and concerns of those patients who travel from afar. The original charge of the Destination Program at the University of Michigan was to create a Destination Program (DP) strategy to address coordination of care for those patients coming from a distance. Patients who travel from over 90 to 100 miles or over one hour have different needs than those patients who live near their care institutions. Our charge was to determine what specific issues needed to be addressed that were different and unique to this population. A culture change to create a new way of thinking was a primary goal. The desired outcome was to move the Healthcare System into being a “Destination Hospital.” A second goal was to increase the number of patients with complex diseases requiring acute care to travel from farther distances to receive this care at the University of Michigan. Marketing alone may increase the number of patients but added volume could cause capacity issues. Our task was to determine what those issues were and to create a plan to address the issues. In turn, to create an “Ideal Patient Care Experience”, for those patients coming to the Institution for care. If the patient and referring physicians’ experience was not excellent, the plan would fail. A prerequisite for this goal was to provide travel-‐sensitive, coordinated care for this population. By creating a “Temporary Medical Home,” during the intake period we would able to ensure accountability at intake. It was also anticipated that improvements in the system, and processes to care for such patients, coupled with enhanced marketing efforts (that highlight the expertise and clinical research) would increase patient activity and provide a “halo” effect for enhancing brand recognition. The ultimate outcome would be:

1. Increased patient volumes for groups of patients with favorable payer mix, 2. Improved revenue to support the healthcare missions, and 3. A greater potential number of patients to enter innovative clinical trials.



In addition, it was expected that the improved systems and processes developed would diffuse throughout the health system to enhance the care provided to all patients. The Destination Program Office also had a vision of serving as the ‘clinical laboratory’ for better processes of care. With this effort, metrics of success were determined by:

• Increased patient volumes from out of state and internationally • Digital campaign metrics showing dollars spent versus returns on patient activity

with positive ROI • Long term metrics showing favorable ROI, calculated by tracking patients through

episodes of care and dollars associated with that patient activity over months, years, and

• An increase in clinical research activity Using Lean techniques with the Gelb Patient Experience Mapping, the University of Michigan DP’s were able to identify “best practices” among the clinics and create a new standard of care for the institution. The next step in the new standard of care involved identifying a “Temporary Medical Home” for each patient to create coordination along the entire episode of care. Standards created for Phase I of the pilot program: Temporary Specialty Medical Home Pilot Program

• Each patient is assigned a “Home Center” based on his or her primary medical/surgical/cancer site.

• The home center is responsible for coordination, financial clearance, and all appointments for that patient during the “episode of care.”

• The Central Access, Call Center, collaborates on patients that cross home centers. The current flow of the patients through the pilot system was characterized by multiple handoffs and specialized functions by many teams, an example of which are, call centers, registration, insurance verification, scheduling, physician triage, evaluation by physician extenders, treatment or procedure scheduling, inpatient teams, discharge planning, and post acute transition care. Care coordination in Destination Programs was focused only on new patient entry into the institution up initiation of care for Phase I. A Journey Coordinator position was proposed, as an enhancement to the pilot but will be discussed in a companion White Paper.



Coordination of care has been defined by AHRQ as:

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care service. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.

Review of Care Coordination Many institutions use specially trained nurses combined with clerical staff to service new patients seeking care. However none of the institutions reviewed use the same resources for treatment navigation. Similarly, teams responsible for coordination or care during a hospitalization or transition care are distinct from those interacting with the patient on entry into the system. A model which takes advantage of the relationships with the patient and family from the first contact throughout the treatment and transition had not to our knowledge, had not been piloted.

Rationale for Action Health care reform will require better coordination of care. The spectrum of coordination of care can range widely from health maintenance to diagnosis to treatment to follow up care of a disease. The numerous touch points within the system make the very effort of care coordination complex. A review of the “episode of care” was plotted out in a Value Stream using Lean techniques. Due to the varying levels of experience with Lean work, we decided to make the Value Stream very basic so that all levels of the health care staff could easily see and understand the work. We started the Value Stream with the intake phone call to the “Central Destination Call Center.” The patient was then triaged to the Patient Financial Counselors for clearance and simultaneously to the clinic for medical acceptance. Once accepted, and if financially cleared, the patient was given a tentative appointment two weeks out. This timing was decided based on administrative needs for insurance verification, clinical needs for medical records and patient needs for scheduling flights, travel and getting their affairs in order.



Once the “Home Center” was selected, which occurred by service line or multidisciplinary specialty clinic, that “Home Center” became the “Temporary Specialty Home” for that Destination patient. This effort created accountability for the Destination Patient and assisted in smoother hand offs to other departments. See Diagram 1.

Diagram 1 Diagram 1 shows the number of steps from intake to clinic scheduling and beyond. The “C” recognizes tasks that can be done by clerical staff, and “N” by nursing staff. The red clinical decision tree boxes note that major clinical decision in care is necessary before moving on to the next step. Physician review is needed at these touch points. The Patient Financial Counselors verify insurance and in many cases have a separate appointment with the patient prior to the clinical appointment. Metrics were measured on the episode of care during this pilot, evaluating the timing standards for scheduling the clinic appointment and for scheduling surgery once the patient was assessed. Discharge home was classified as to the patients home state or county because many patients stayed in the Ann Arbor area for a period of time after discharge from the hospital for follow up and further evaluation needed before returning home. It was from this value stream exercise that accountability was needed to improve the patient care experience. This was also verified by the Gelb Experience Mapping results.

Designate Temporary Specialty Medical Home



In summary, improved coordination of care for Destination Patients from the first patient contact though the evaluation, treatment planning, treatment, and transition care addressed many of the deficiencies in current care process, and improved performance. This unique coordination of care model was piloted for four years. It also transitioned with a new EMR. The capabilities and synergism of which were not yet discovered. The “lessons learned” from this model included a need for a person to step in during hand offs to ensure that patients flowed smoothly through their experience, at least in the transition period. The Destination Program Office performed this function during the pilot. The next step, Phase II, was to explore the “Temporary Specialty Medical Home” concept using of a team of clerical and advanced nursing personnel to coordinate care for patients with complex diseases requiring acute care and using a Journey Coordinator to oversee the care during the hand off touch points. Please see White Paper “Using Journey Coordination for an Ideal Patient Care Experience.”



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Using A Nursing Coordination of Care Model

Health & Medicine

Transcript of Using A Nursing Coordination of Care Model