Executive Summary
Horizon Blue Cross Blue Shield of New Jersey members who received care at patient-centered physician practices had fewer emergency department visits and inpatient admissions, and a higher rate of diabetes control and cholesterol management than patients receiving care at traditional primary care practices.
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Population care coordinators who work at the patient-centered practices help at-risk members navigate the health system and manage their conditions.
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The population care coordinators focus on the top 5% to 10% of patients who are sickest, but who potentially can control their conditions.
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They focus on patients with gaps in care and those who have multiple emergency department visits.
Horizon Blue Cross Blue Shield of New Jersey members who received care at patient-centered physician practices were able to avoid more than 1,200 emergency department visits and 260 inpatient admissions, which represents a savings of approximately $4.5 million, according to Carl Rathjen, the health plan’s manager of network strategy and program development.
The members had a higher rate of diabetes control and cholesterol management, and a lower rate of emergency department visits and hospital admissions compared to members receiving care in traditional primary care practices, a 2013 internal study showed. Outcomes for the 200,000 patients in the patient-centered medical home included a 14% higher rate in improved diabetes control, a 12% higher rate in cholesterol management, an 8% higher rate in breast cancer screenings, and a 6% higher rate in colorectal cancer screenings.
A key component of the program is population care coordinators, which are nurses who work at participating practices and help at-risk members navigate the healthcare system and manage their conditions, says Steven Peskin, MD, MBA, FACHE, senior medical director, clinical innovations, for Horizon Blue Cross Blue Shield of New Jersey.
The health plan is collaborating with patient-centered practices in more than 900 locations throughout New Jersey. Small practices may share a population care coordinator. Larger practices may have as many as a dozen. The nurses work at the individual practices and meet patients in person as well as corresponding by telephone, email, and text messages.
Members are identified for interventions by health plan data as well as referrals from members of the practice treatment teams. The individual practices take the data from the health plan to help risk-stratify the patient population, Rathjen says.
"We’re not prescriptive about who is on the list for outreach. We provide a list of people who are likely to need interventions, but the providers know their patients and may add other individuals," Peskin says.
"All Horizon Blue Cross Blue Shield members being treated by the practice are eligible for the program whether they are the young or the frail elderly or anyone in between. They may not need services, but when they do, the population care coordinator and the rest of the team are there for them," Peskin says.
The population care coordinators focus on the top 5% to 10% of patients who are sickest, but who potentially can control their conditions if they become engaged in managing their healthcare, he adds. The patients targeted may have multiple comorbidities, medication issues, or have chronic conditions like diabetes or be undergoing treatment for a serious illness like cancer, he says.
The population care coordinators contact any member who has been hospitalized or visited the emergency department to make sure he or she gets a follow-up appointment within 72 hours of discharge if necessary, he says. They develop care plans for members who are at risk and make sure they get the help they need to keep their conditions under control.
"The population care coordinators also reach out to patients who have been going to the emergency department repeatedly. Sometimes that may be a warning sign of an underlying condition," he says.
A key focus is identifying gaps in care and ensuring that members receive the recommended tests and procedures, such as diabetic foot exams and mammograms. "This new model strengthens and builds trust between the physician and the care team and the individual patients. If patients identify the person calling to remind them of a recommended test as being from their doctor’s office, there is a better chance they’ll follow through than if the call came from a health plan," Peskin says.
The health plan encourages practices to provide team-based care, and has prepared a playbook that helps the practice ensure that everyone performs at the top of his or her license and that everyone on the staff works together as a team.
"Better care is delivered if all persons working in a practice have a sense of being part of a team," he says.
For instance, before a patient comes for an appointment, the care coordinator may tell the physician about a concern the patient mentioned during a phone conversation.
To develop the program, the health plan worked with a physician advisory board of seven family practice physicians and one internist who collaborated on the key elements of the program and continue to give feedback, Peskin says.
With the help of the physician advisory board, the health plan developed a sample job description for the population care coordinators. The care coordinators are hired by the practices and undergo a two-day training session developed by Horizon Blue Cross Blue Shield of New Jersey. The health plan hosts quarterly meetings at two different locations where the care coordinators can share best practices and brainstorm with their peers on challenging patients, he says.
The health plan also launched a pediatric program in January 2014 with a major focus on preventive services, immunizations, and developmental screening.
Horizon Blue Cross Blue Shield of New Jersey rewards practices for improving the patient experience and improving patient care, Rathjen says. "We also provide up-front support to help transform the offices and to hire the care coordinators," he says.
