An initiative that included hiring an RN care coordinator to work with patients who needed a higher level of care, or had gaps in care, resulted in significant improvements in preventive care exams, lower costs for hospitalizations, and a decrease in emergency department visits for patients in the program at Jackson Clinic, a multispecialty practice with 136 providers in western Tennessee.
The results are from Jackson Clinic’s first year of participation in Cigna’s collaborative accountable care initiative, which rewards participants for achieving the "triple aim" of improved health, affordability, and patient experience.
During calendar year 2012, the first year of the program, Jackson Clinic outperformed the market in Cigna quality of care measures, according to Renee McLaughlin, MD, Cigna’s senior medical director for Tennessee. For instance, the clinic performed 19% better than its peers for annual eye exams and 25% better for annual screenings for kidney disease for people with diabetes, and 50% better than the market for adolescent well care visits.
"A key to the success was having a care coordinator who was working in the organization and helped close gaps in care. We were early adopters of the electronic medical record, and the information we have in those records, plus information from Cigna’s claims data, helped us target the patients who needed an intervention from the care coordinator," says Keith Williams, MD, FACOG, chief medical officer for Jackson Clinic.
About four years ago, the physician-owned organization began preparing for the shift in healthcare from fee-for-service to fee-for-value, Williams adds. "We knew that if we wanted to provide high-quality care at a low cost, we needed a partner. When Cigna approached us with its collaborative accountable care model, we partnered with them," he says.
Cigna offered the clinic a proposal to continue fee-for-service reimbursement, and also to share any savings in the cost of care.
In the first year, the practice hired an RN care coordinator whose salary was covered by Cigna’s care coordination fee. After the first year showed significant savings in closing the gaps in care, the practice added 1.5 FTE RN care coordinators and is developing multidisciplinary physician-directed care teams that include RN care coordinators, nurse practitioners, and LPN medical assistants, he says.
The teams educate patients with multiple conditions on how to take better care of themselves and follow up with patients who have had hospital admissions, Williams says.
"The goal is to drive quality up and costs down while helping patients take their medication as directed, follow their treatment plan, and see their primary care provider regularly so they avoid emergency department visits and hospitalization," he says.
When a patient is identified for the program, the care coordinator researches the medical record to determine if there are gaps in care or any pattern of emergency department use or hospitalizations that indicate disconnected or costly care, he says. They call the patients, educate them on their conditions and medication regimen, and make the primary care physicians aware of any issues their patients are having that may necessitate modifications on the clinical side.
"Identifying and closing gaps in care is still critical, but where that once was the main focus, now our focus is developing the care team to provide coordinated care for patients," Williams says.
Using a computer platform provided by Cigna, the care coordinators can access information in the insurer’s database to give them information about patients who need interventions, says Sarah Johnson, MHA/INF, RN, director of the clinic’s clinical informatics and population health management department. For instance, a care coordinator can select the daily inpatient census list and call patients after discharge to schedule a follow-up visit with their primary care provider within seven days.
"Whenever the care coordinators pull up a registry, they see information about the whole patient," Johnson says. For example, if the care coordinators access information on breast cancer screenings, they can see all of a patient’s disease processes, other gaps in care, and whether they are receiving case management from a Cigna care coordinator.
The care coordinators at Jackson Clinic are aligned with specific case managers at Cigna and have standing appointments to discuss particular cases and what interventions they need, says Harriet Wallsh, RN, director of Cigna collaborative care clinical operations.
If the case managers in the practice need information or want to refer a patient to a Cigna program, they know they will always get the same case manager, Wallsh says.
The nurses embedded in primary care practices also are supported by a team of field nurses who meet with them face to face, Wallsh says.
"We see ourselves as an extension of the practices, so we work closely with collaborative partners to make sure our customers get the services they need to stay healthy and to optimize health outcomes," she