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The Carle Clinic Association in Mahomet, IL, carefully screens the patients who are chosen to participate in its Partners in Care case management program. The typical patient has two or more chronic conditions, such as congestive heart failure, diabetes, cancer, stroke, or coronary artery disease, and takes at least five medications daily. Patients have limitations in activities of daily living (such as walking or feeding themselves), limited instrumental activities of daily living (cooking, driving, and shopping), and a history of previous hospitalizations.
Over time, the practice has automated its system of identifying patients at risk who should be referred to the program. "We are continually refining and automating our clinical records and triggering systems," says Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center.
Medicare patients who have seen a family practice or an adult medicine physician more than four times in a year are automatically referred to the program. Patients also are referred to the program directly by physicians. Once a patient is referred to the program, he or she receives a 50-item questionnaire that gathers information such as demographics, medications, current health conditions, and prior health care utilization. The information from the questionnaire is entered in a computer database that classifies patients into risk categories based on responses to the questions.
If a patient has positive responses to three of 13 "trigger" questions, he or she is initially given a status of "At Risk." A "nurse partner" conducts a second, more detailed screening either during an office visit or over the telephone. Using this information, the nurse partner and physician determine the patient’s final risk status.
Participating patients are given a medical assessment by the physician to determine current and potential medical and psychosocial needs. Then, the patient, physician, and nurse partner develop a coordinated health care plan that includes medical services, community services, and assistance from family, friends, and neighbors.