CMSA Today - Issue 2, 2013 - (Page 8)

Home Initiatives Role of the Nurse Care Manager in a PatientCentered Medical Home Lessons Learned from the Massachusetts Patient-Centered Medical Home Initiative BY CHRISTINE JOHNSON, PH.D., TRANSFORMATION AND QUALITY IMPROVEMENT DIRECTOR, MASSACHUSETTS PATIENT-CENTERED MEDICAL HOME INITIATIVE; PCMH QI AND TRANSFORMATIONAL DIRECTOR, UMASS MEDICAL SCHOOL MARGARET HOUY, J.D., MBA, SENIOR CONSULTANT, BAILIT HEALTH PURCHASING, LLC B ringing a nurse care manager into a primary care practice that is transforming into a medical home not only adds a new function, but also revolutionizes how health care services are rendered. A patient-centered medical home is best understood as a model of primary care based on patient-focused, population management principles. These principles require practices to stratify their patient panels by risk, and implement proactive interventions based on the patient’s level of risk and specific needs. A medical home operates by reaching out to healthy patients to schedule their annual physicals and preventive screenings, providing care coordination and test tracking to patients needing assistance to obtain specialty services, and providing intensive care management services to the highest risk patients to avoid unnecessary hospitalizations and ED visits. To provide that level of differentiated, engaged services, the old model − consisting of the physician leading a team of subordinates to serve only patients who have appointments − gives way to a multi-disciplinary care team model in which each member has responsibilities that maximize his or her training and personal capabilities, combining to work together across the system. Moreover, the care team 8 CMSA TODAY Issue 2 • 2013 provides services to the entire patient population attributed to the practice, which involves proactive outreach to the patients who have not regularly scheduled appointments. Within the multi-disciplinary care team, the nurse care manager is responsible for providing intensive care management services to the highest risk patients, who make up approximately 5 percent of the practice patient panel who are most at risk of relapse, an ER visit or hospitalization. To serve these patients, the nurse care manager must often reach out to the patients who have poorly controlled conditions and often have behavioral health co-morbidities. Based on our observations in the Massachusetts Patient-Centered Medical Home Initiative, which we will discuss below, these outreach efforts have proven to be more effective than payer outreach because the nurse care manager is an integral part of the care team. The role of the nurse care manager in a medical home is essential if the medical home model is to be sustained. The nurse care manager’s focus is to prevent avoidable inpatient hospitalizations and ED visits, which translates to direct cost savings for the health care system. Those savings are essential to fund other practice changes associated with medical homes, such as EMRs, patient registries, daily team meetings, and proactive patient outreach. The Massachusetts initiative, which is piloting a 46-practice patient-centered medical home initiative focused predominantly on Medicaid practices,1 indicates that there are several key factors that determine if the nurse care manager will be successful. This article discusses each of the success factors and barriers to achieving success. KEY SUCCESS FACTORS FOR BUILDING A PRACTICEBASED CARE MANAGEMENT SYSTEM: LESSONS LEARNED FROM MASSACHUSETTS Build a Multi-Disciplinary Care Team Building a multi-disciplinary care team involves changing roles so that everyone is working to the top of their professional capacity, allowing much of the work to be done by team members other than the physician. This way of working involves regular and ongoing communication, both real time and

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2013

President's Letter
Role of the Nurse Care Manager in a Patient-Centered Medical Home
Association news
View from Capitol Hill
Case Management and the Law
Ethics Casebook
Mentoring Matters
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 2, 2013