Program identifies patients who need extra help

Gaps in care, hospitalizations targeted for outreach

The collaboration between a commercial health plan and a physician group practice will be able to promote optimal care for patients because the partners have a different focus and outlook, says Barbara Walters, DO, senior medical director for Dartmouth-Hitchcock.

"The commercial health plan will use claims information to identify patients who need extra care. We look at the patients in a clinical contact context to identify patients who we think need extra care. Using the two methods, we can better identify patients who can benefit from extra care and adopt them into a medical home," she says.

The health plan and physician practices are collaborating to identify patients who are eligible for the care coordination part of the program, Walters says.

The physician office maintains an electronic registry for people with chronic diseases and mines the data looking for lab tests or gaps in care to identify patients who need a call from a nurse. In addition, physicians can suggest individual patients who would benefit from care coordination.

"There are certain patients who are fragile and/or who have complicated conditions and complex need. They need a little more attention than they can get in the random or sick visit access of the health care system. Our program aims to find patients who fit this profile and give them the extra attention they need," she says.

When a patient is identified as needing extra help, a nurse makes an outbound call and talks to the patient about his or her health care issues.

When targeted patients have an appointment with a Dartmouth-Hitchcock physician, a nurse case manager examines the patient record the day before the visit and makes sure that all laboratory tests results and other pertinent information is available to the doctor. The day after the visit, the nurse calls the patient, discusses the visit, and answers any questions.

"We all know it's very difficult for a patient to absorb everything that happens during a pressurized patient visit scenario. That's why the nurse follow-up is important," says Dick Salmon, MD, national medical director for CIGNA.

When patients are discharged from the hospital, a Dartmouth-Hitchcock nurse care coordinator calls them to review their hospitalization, their treatment plan and medication regimen, and to ensure the patient has a follow-up visit.

"Patients are stressed when they are in the hospital, and they can't remember everything they are told. When they make an acute care visit, they may think of questions or concerns after they get home. Our nurses follow up and help them understand what's going on and help them follow their treatment plan," Walters says. The nurses work with patients to help them come up with common objectives and strategies to meet those goals.

"Patients adore the program. They like getting a call from a nurse. Our nurses were trained to become expert health coaches and advocates on behalf of the patients, either in person or on the telephone," Walters says.

Patient portal facilitates communication

To further facilitate communication, the physician practice has developed a secure electronic patient portal that patients can use to access their medical records and communicate with their physicians.

"Patients are encouraged to look into the medical record and see what the doctor wrote so they can confirm what they thought they heard or didn't hear," she says.

They can send an e-mail with questions and clarifications to their health care team. "This helps get the patient the information they need more quickly and eliminates telephone tag," she says.

Patients who use the electronic patient portals tend to open up more than they do on telephone calls, Walters says.

"They have time to collect their thoughts and feel more comfortable asking things in writing that they may be embarrassed to ask in person," she says.