Care coordination generates savings

Model calls for CMs in primary care offices

A study of three primary care practices that participate in Cigna’s Collaborative Accountable Care model, which includes care coordination for at-risk patients, showed significant cost savings and improved quality of care when compared with other practices in the same geographic area.

Cigna developed collaborative accountable care in 2008 as a way to create a patient-centered approach and an outcomes-based payment system, says Harriet Wallsh, director of collaborative solutions and effectiveness. One of the requirements for the program is for the practice to employ an RN care coordinator to work with patients and providers. “The care coordinators are the link between the patients, the doctors, and the insurer,” Wallsh says.

In a typical practice, about 3% to 5% have chronic conditions or complex care needs that make them eligible for the care coordination program, Wallsh says.

Cigna aims for a ratio of one care coordinator for every 10,000 Cigna customers and provides an extensive educational program that orients the care coordinators on how to use the patient-specific data that Cigna provides. Where the nurses are located is up to the individual practices, Wallsh says. Some physician groups with multiple offices may have care coordinators in a central location. Some meet the patient person to person, but many work with them on the telephone. (For details on how one physician practice’s care coordination program works, see below).

The health plan provides detailed reports to the nurse care coordinator on a daily, monthly, and quarterly basis that helps him or her target patients for interventions. The reports include patients with gaps in care, patients who are not filling prescriptions in a timely fashion, and those who are in the hospital, as well as those the health plan determines by predictive modeling are at risk for an inpatient admission, an emergency department visit, or exacerbation of a chronic condition.

“We share information that helps the nurses identify patients who need a higher level of touch and they contact the patients,” Wallsh says.

The care coordinators have access to claims information from Cigna as well as information in the patients’ medical records. “This gives the clinical staff the big picture about the patient that enables them to put together a comprehensive plan,” she says.

For instance, if the nurse care coordinators see that a patient has missed appointments or has gaps in care for recommended diabetes care, they call their counterparts in Cigna to see what benefits the patient’s employer has that could help him manage his diabetes. “Then the care coordinator calls the patient with full knowledge of Cigna programs or local programs for diabetics,” she says.

“The care coordinators prevent fragmentation of care by identifying patients in need and intervening,” Wallsh says.

When care coordinators get a report that patients are in the hospital, they call them while they’re still in the hospital or immediately after discharge and help them set up follow-up appointments with their primary care physician. The care coordinators at the medical practices work closely with the Cigna case management staff and each embedded care coordinator is assigned to a specific Cigna staff member. “This gives both nurses the opportunity to build a relationship and provide better continuity in care,” Wallsh says.

CMs build relationships with physician practice

Nurses work with insurer to fill gaps in care

When patients at Fairfax (VA) Family Practice who are covered by Cigna are hospitalized, the primary care practice’s care coordinator calls them not necessarily to intervene in every case, but to let patients know that their physician office cares to make sure they’re recuperating and assess their needs.

“Sometimes, the patient doesn’t have any needs, but the fact that someone from the physician office is checking on them helps build the relationship that is key in a medical home,” says Lauri Rustin, chief executive officer of Fairfax Family Practice, which participates in Cigna’s Collaborative Accountable Care model. The primary care provider has 12 practice sites staffed by about 108 providers. The practice has one care coordinator, with plans to hire a second nurse in 2013.

Cigna sends the practice a daily report of patients in any facility, including hospitals and long-term acute care hospitals. “Our care coordinator monitors these daily reports until the patient no longer is on the report. As soon as patients are discharged, she contacts them to get them into the office within seven days,” says Susie Smith, PhD-c, RN, NE-BC director of quality for the physician practice.

The practice also participates in a residency training program for family practice physicians through Virginia Commonwealth University. “The residency program helps us coordinate care with our patients who are hospitalized because we have people in the hospitals who can give us the information we need for follow-up care,” she says.

When patients are discharged, the care coordinator contacts them and assesses their needs, then works with a Cigna case manager to determine if the patients have benefits that could help them, such as smoking cessation, weight loss programs, or chronic disease management. The care coordinator checks the electronic medical record for patient medication and compares it with the medication prescribed in the hospital. She works with the patient’s primary care physician to get orders for physical therapy, durable medical equipment, or other post-discharge needs.

“The care coordinator is the health coach within the team the physician oversees. They see that the physicians have better information and that the patients have better access to the resources they need,” Smith says.

Depending on the needs of the patients, the care coordinator may make multiple telephone calls over a period of time, checking back to see how the patients are doing and helping them navigate the healthcare system.

For instance, one patient was being denied coverage for back surgery after it was completed because of a misunderstanding between the provider and the insurer. “Because our care coordinator had a relationship with Cigna, she could go directly to the right person and get the problem cleared up,” Rustin says.

The care coordinator works with patients who have had a hospital stay as well as those who are frequent users of the emergency department or have incurred high healthcare costs.

“When patients who are high cost are on the list from Cigna, the care coordinator reviews the medical record, then calls the patient to find out what is going on,” she says.