Care coordinator for complex needs

Collaboration with treatment team is key

AmeriHealth Mercy's care coordinator, Lynne Major MSW, CCM, touches base with every member who comes into the physician office where she works, encourages them to call her if they have questions and spending extra time with those who have complex needs.

Major meets with all the members covered by the Philadelphia-based health plan at least once and conducts a comprehensive assessment that includes a medical and psycho-social assessment, as well as the patient's individual motivation and confidence to manage their own care. She gives members without complex needs her card, and she encourages them to call if they have questions or concerns.

Karen Michaels RN, MSN, MBA, vice president of clinical services for AmeriHealth Mercy says, "She touches base with any of our members who come into the office, even if they have no special needs. When patients need extra support, she spends time with them while they are in the office."

She follows those with complex needs through the continuum, contacts them between visits, and helps them access health plan resources, such as diabetic educators. When members schedule an appointment, the care manager compiles as much information as possible on the patients the day before they are scheduled for a visit, and she organizes it for the office staff. Major has daily huddles with the treatment team to discuss who is coming for an appointment that day and who has special needs.

She identifies any gaps in care based on national guidelines for chronic condition, and she uses the health plan database to access pharmacy utilization information. In some cases, Major has determined that the patient is taking a medication prescribed by a different physician and that it might interact with something else the patient is taking.

While patients are in the office, Major visits them and conducts a brief assessment to identify the barriers to care the members are dealing with at that particular time. She updates the physician and works on overcoming the barriers, connecting the members to resources at the health plan, referring them to the community food bank, or helping them with housing assistance applications. Major educates patients about their condition and coaches them on ways to adhere to their treatment plan. She helps them access community resources or get appointments for tests and procedures or visits with specialists.

Grace Lefever, PT, MS, MPH, project leader for coordinated care management at Mercy Health System, based in Philadelphia, says "The care manager helps patients overcome barriers to care that are difficult to address in the physician's office. She is able to improve all the connections to resources in the community and help the member deal with whatever issues are interfering with their care," Lefever says.

When patients are hospitalized, the care manager in the physician office works with the hospital case manager, the health plan case manager, the health plan's pharmacist, and behavior health staff, if appropriate. The health plan also has a transition manager at the hospital who works with the patients and the hospital case manager on the discharge plan.

All of the health plans care managers go through training on motivational interviewing and engagement techniques as well as available community resources.