CMs partner with docs to help high-risk elderly
CMs partner with docs to help high-risk elderly
Concept evolved over 12-year period
When the Carle Clinic Association launched its Partners in Care program for the elderly, the Mahomet, IL-based multi-specialty practice already had 12 years of case management experience with seniors under its belt. The current program evolved from a case management model designed to address the needs of the rapidly growing geriatric population the clinic leaders knew they would be serving in the future.
"We went through a lot of changes in the model. We started with volunteers, then nurse/social workers, and finally found that the best solution was a community-based specially trained nurse," says Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center. Carle Clinic Association started a case management program for the elderly in 1986, with initial funding from the Kellogg Foundation, Schraeder says.
"When we started the concept, it was ahead of its time. There was nothing like it in group practice in the country," Schraeder says. "Most of the case management at that time was in the social service field with under-served populations, primarily in psychology and public health."
At the time, nurses were not an integral part of case management programs. This was a concern to the Carle Clinic leadership because they had found that older adult patients, particularly those from the rural areas served by the clinic, often were reluctant to describe accurately how well they were functioning.
The clinic doctors and nurses had found that the patients felt freer to discuss their living situations and health problems with the nurses, rather than the doctors. The solution seemed to be an integrated program in which the nurse works with the primary care physician, the patient, and the patient’s family to develop and coordinate a health care plan.
The practice tried having all of the nurses working in a centralized setting, then moved on to having them decentralized but in their own space. They found that it was most effective for the nurses to be in the community clinic setting where they can be aligned closely with the primary care physicians to enhance the team treatment concept. That led to the current system in which the nurses, called Nurse Partners, are located in clinics throughout the clinic’s treatment area and are responsible for managing the care of patients for specific primary care physicians.
"We tried all kinds of communication with physicians, including e-mails and written summaries, but we found that if the physicians and nurses are in the same facility, they can communicate in the hallway or before the start of the day and do quick case reviews instead of scheduling long-term meetings," notes Schraeder.
The clinic is one of 15 sites chosen to participate in a Medicare Coordinated Care Demonstration Project. It is taking the same concepts and applying them to chronic conditions such as diabetes, chronic obstructive pulmonary disease, coronary artery disease, stroke, and congestive heart failure.
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