CMs in physician offices report high satisfaction
They collaborate with health plan resources
Nurses who coordinate care for patients in physician offices as part of Cigna's Collaborative Accountable Care model have a high rate of job satisfaction, says Harriet Wallsh, director of Cigna collaborative care clinical operations.
"Nurses got into the profession because they care about patients. They like to deliver care. If they can reach out and help a patient keep healthy and improve his quality of life, they have had a positive impact on a person and enjoy their job," she says.
Care coordinators are a key component to Cigna's Collaborative Accountable Care initiative, Wallsh says. "The care coordinators are the pivot point between the doctor and Cigna. They are employed by the Collaborative Accountable Care organization and work closely with Cigna health improvement programs and services to make sure patients get the care they need to optimize their health. By working with the Collaborative Accountable partners to leverage our collective strengths, we are improving patient care and satisfaction and lowering costs," she says.
Cigna started its Collaborative Accountable Care initiative in 2008 and now is working with 86 practices with more than 35,000 physicians. The goal is to expand the program to 100 practices in 2014. Cigna compensates the physicians for medical and care coordination services and has a pay-for-performance program to reward physicians if they meet targets for improving quality and reducing costs. The initiatives have produced a lower cost trend, and patients in the program have fewer avoidable emergency department visits, fewer gaps in care, better compliance with evidence-based care, and receive more preventive care.
Care coordinators are clinicians and receive extensive training that includes face-to-face education, webinars, telephonic training, and outreach on a regular basis. They are connected to resources within Cigna who can assist them in meeting patient needs.
For instance, one care coordinator worked with a family whose child was being released from an inpatient psychiatric facility on a Friday afternoon and couldn't get a behavioral health follow-up appointment for 30 days. The care coordinator contacted Cigna's Behavioral Health staff, who arranged an outpatient visit for the child the next day.
The embedded care coordinator role is tailored to what each individual practice needs and how the practice operates. Some may coordinate care for patients in multiple practice sites and work in a central location contacting patients strictly by telephone. In other cases, the care coordinators may be embedded in the practice site and see some patients in person when they come into the office or when they are hospitalized if the practice is near the hospital.
The care coordinators identify patients with whom to intervene through multiple reports Cigna provides at regular intervals, listing patients who have been hospitalized, those who have gaps in care, and those who are at risk for high healthcare costs.
When patients are in the hospital, the care coordinators are alerted and call the patients while they are in the hospital, or within 72 hours of discharge to ensure a smooth transition. They find out how they are doing, answer any questions about their treatment plan, make sure that they have filled their prescriptions, and arrange for follow-up appointments as needed.
"The care coordinators make sure patients get back to see their primary care provider quickly and have a specialist appointment if they need one. They go over the treatment plan and medication regimen and make sure the patients have everything they need to avoid a readmission," she says.
The care coordinators also contact patients who are on a monthly predictive modeling report that identifies patients who are at risk for high healthcare costs. This includes patients with excessive inpatient admissions or emergency department visits, those with high-risk injuries or illnesses, or a combination of conditions that trigger an alert.
For instance, if the report shows that a patient has been to the emergency department more than three times in six months or six times in 12 months, the care coordinator reviews the medical record to determine the diagnosis and reason for the visits, then follows up with the patient to find out what the issues are. "It could be that the patient wasn't using an asthma inhaler as directed or taking insulin regularly and had an acute episode. Or the patient was having a medical issue, such as frequent migraine headaches, and didn't realize he could call the primary care provider for treatment," Wallsh says.
In those cases, the care coordinator works with the patients to get them a primary care appointment to treat the problem, educates them on how and when to take insulin or use an inhaler, and/or educates them on the appropriate use of the emergency department.
Cigna sends care coordinators monthly gaps in care reports, shares the same information with providers, and sends letters to the patients reminding them to get the recommended preventive test or procedure. The care coordinators follow up with patients on the list to help overcome whatever obstacles they have to following their physician's recommendations for preventive care.
They also contact patients who are not filling their prescriptions, determine the reason, and can call on Cigna's pharmacy staff for assistance. For instance, if patients say they can't afford the medication, the care coordinator can call on Cigna's pharmacy staff to help the physician identify alternatives. "The pharmacist may help the patient fill the prescription through Cigna's mail order program monthly, instead of quarterly, with an aligned patient cost or, in some cases, may be able to get the patient free medication," she says.
The care coordinators work closely with Cigna's case managers, disease managers, and health coaches to make sure patients' needs are met. Often, they collaborate with the Cigna case management staff to develop a coordinated care plan. For instance, Cigna's case managers typically coordinate care for conditions that include cardiac, complex gastrointestinal, and respiratory conditions. When patients need complex case management, the Cigna case managers take over coordination until the patient stabilizes, then turn it back over to the embedded care coordinators. However, the two clinicians may continue collaborating on the patient's care.
The care coordinators follow up with patients at intervals that vary according to patient needs. They may work with some for a short period of time or follow others indefinitely.
"By coordinating our resources with those of the Collaborative Accountable Care office, we are helping our members get healthier and stay healthier, and saving money at the same time," Wallsh says.