What is the challenge?

Patients with more complicated physical and/or mental illnesses are at increased risk of potentially serious, even fatal, exacerbations and complications. They may benefit from more intensive follow-up and management than can be done through repeated office visits. Many patients being discharged from the hospital or Emergency Department fit this description. Evidence suggests that well-organized care management by a nurse or other health professional can reduce patients' risk of deterioration and readmission, and the associated health care costs. One-half of patients readmitted to hospitals within 30 days of discharge have not seen a community provider.

What needs to change?

Primary care practices should try to establish a care management program with the following characteristics:

  • RNs serve primarily as care managers complemented by social workers if available.
  • Care managers are integrated with primary provider, team, and the Electronic Health Record.
  • Proven strategies for identifying potentially appropriate patients.
  • Trained nurses who can provide clinical monitoring, oversight of drug therapy, and self-management support.
  • Regular follow-up with patients that includes some face-to-face contact.
  • Regular review of care-managed patients with clinical experts.

What do we gain by making these changes?

With effective care management, your practice can improve disease control and self-management, reduce distress, prevent admissions or readmissions, and improve the coordination of care for more complex patients. Care management contributes significantly to a practice’s ability to reduce total costs of care.

  1. Think about care management as a program, not a person.

    Patients with a wide variety of clinical and behavioral problems may benefit from care management. Patients with mental health problems and/or social and economic challenges may also benefit from case management services from a social worker. Less complicated patients needing only closer monitoring can be followed effectively by a trained MA or lay person using a protocol and supported by a health professional.

  2. Shift RN roles toward care management.

    RNs have become much less common in primary care practice settings. But many still spend much of their day fielding incoming phone calls and giving injections. Many LEAP practices are finding different ways to manage phone calls (see communication management module) and injections to free up RN time for care management. Additional training may be necessary for some RNs to play this new role.

  3. Decide which patients to refer to care management.

    Most care management programs target patients with high costs and/or high utilization, and many use computerized risk prediction algorithms to identify candidates. Others focus on patients being discharged from the hospital or patients referred by providers in the practice. The practice should be clear which patients it wants to target, but payers generally expect total cost reduction through reduced hospitalizations and Emergency Department (ED) visits. 

  4. Establish relationships with key hospital(s) to identify and co-manage patients discharged from the hospital.

    To effectively support patients through transitions, practices need to know as soon as possible when their patients are seen in the ED or hospitalized. This often requires that the practice initiates conversations with hospital/ED administrators and care management staff to ensure early notification and coordination of post-discharge care.

  5. Create protocols, standing orders, and standard work flows.

    Just giving a nurse a list of high-risk patients to call is unlikely to improve outcomes. Effective care management programs are guided by explicit protocols that describe:

    • Expected size of case load.
    • Frequency, modes, and duration of patient contact.
    • Use of assessments.
    • Role in medication management (see Medication Management topic).
    • Interactions with patient’s primary care provider and team.
    • Documentation in the Electronic Health Record and elsewhere.
    • Discharging patients from care management.
  6. Make sure care managers have protected time to do their work.

    To ensure that a care management program is effective, it’s important to create protected time for nurses or other care management staff. If they get pulled away to cover the phones or do a dressing change, the essential work of care management will not get done. Having leadership support for protected time is essential.

  7. Develop a support structure for care managers.

    Most successful care management programs ensure that nurses regularly review their cases with relevant clinical experts. This could be with a multi-disciplinary team that includes a provider or other clinician, social worker, behavioral health specialist, clinical pharmacist, or others. Or the practice can designate a consulting clinician (other than the primary care provider) for this role. In addition, nurse care managers have major documentation and administrative burdens and often need help meeting their patients’ social needs. In response, several LEAP sites have linked nurse care managers with MAs, administrative staff, or social workers.

Publications

ToolkitsImplementation guides and other documents with extensive resources included

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Care Coordinator Job Responsibilities

    Learn about the responsibilities of the care coordinator at one LEAP site. Working with a nurse care manager, the MA care coordinator supports care management focused on the highest-risk patients.

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  • Role features

    Nurse Care Manager Job Responsibilities

    Learn about the responsibilities of the nurse care manager at one LEAP site. The nurse care manager works with an MA care coordinator to provide care management focused on the highest-risk patients.

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  • Role features

    Health Coach Job Description

    Here is a job description of an MA health coach that is part of the centralized care management team at Penobscot Community Health Care.

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  • Role features

    Care Manager Job Description

    Here is a job description of a nurse care manager (RN) that is part of the centralized care management team at Penobscot Community Health Care.

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Webinar and power point presentations

  • Webinar and power point presentations

    Models of Complex Care Management

    Learn how 4 LEAP sites approach care management. Notice that these are very different organizations serving different patient population needs.

Staff trainingTutorials, training manuals, etc.

  • Staff training

    Transitions of Care Management (TCM Code) Tutorial

    Learn how one LEAP site has trained team members on coding to reimburse services under the new Transition of Care Management code.

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  • Staff training

    High-Risk Case Management Overview

    Learn about the high-risk case management approach at one LEAP site, in determining how to best allocate different types of team-based care to patients based on their level of risk and need. You can find protocol related to the high-risk case management services in our collection of tools in this topic

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  • Staff training

    Case Conference Description

    Learn about one LEAP site's approach to multidisciplinary case conference reviews of patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

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  • Staff training

    Complex Case Management Care Plan

    Learn about one LEAP site's approach to multidisciplinary case conference reviews, by looking at the care plan notes from one of these sessions for patients in the complex care management program. The nurse care manager invites relevant clinical experts, including the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed. Each team member brings different types of insight and suggestions for making improvements to the patient's care plan.

    Attribution:

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Risk Stratification using a modified LACE Tool

    See how one LEAP site, Penobscot Community Health Care (PCHC), risk stratifies patients to direct the level of services needed for patient with complex health conditions. The highest risk patients are admitted to a robust complex care management program, then assessed using the modified LACE tool. PCHC developed a workflow involving the MA Health Coach, RN Care Manager, and social worker who are part of the complex care management team.

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  • Clinical protocol

    Hospital Pre-Discharge Virtual Patient Interview Protocol

    Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

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  • Clinical protocol

    Care management discharge criteria

    Learn about the criteria that one LEAP site uses to discharge patients from care management, once they have reached their clinical goals.

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  • Clinical protocol

    Hospital Transition Intake

    See protocol used by nurse care managers at one LEAP site during a transition follow-up after patients are discharged from the hospital.

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  • Clinical protocol

    Transition Care Clinical Protocol

    See protocol used by nurse care managers at one LEAP site for patient care transitions.

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  • Clinical protocol

    RN ER Case Management Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to follow-up after patients have an ER visit.

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  • Clinical protocol

    Complex Care Management Intake Clinical Protocol

    See protocol used by nurse care managers at one LEAP site when patients are admitted into the high-risk case management program.

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  • Clinical protocol

    RN Complex Care Management Case Conference Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to conduct a multidisciplinary case conference review of patients in the complex care management program who need a new or revised care plan. The Nurse care manager invites relevant clinical experts, which includes the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed.

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WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Hospital Pre-Discharge Virtual Patient Interview Workflow

    Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

    Attribution:
  • Workflow

    Hospital Transition Overview

    Learn about one LEAP site's organizational approach to care transitions in this document, which reflects the commitment to collaborating with all of the hospitals where a majority of their patients seek care and having a process for timely information exchange with each hospital. Leadership, providers, and nurses all have a critical role in creating and maintaining processes so that patients experience a smooth transition across care settings.

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