EXECUTIVE SUMMARY
An outpatient case management and care coordination program targeted a population of people with diabetes to improve quality of life and medical care.
- After a chart review, nurse navigators identified problems that could be fixed and result in positive outcomes.
- After the first 16 weeks, the program had 80% of the 534 patients drop five points in their A1c tests.
- Nurse navigators provide health education and help patients with social needs.
As health systems are evolving to population health models seeking to keep chronically ill patients out of the hospital, they’re using case management in the community setting as a tool to achieve this goal.
It’s challenging work to improve the health of a population of people, particularly with people who have been sick — or at least not healthy — for a long time, such as a diabetic population. “We’re working really hard on getting our patients where their disease is manageable,” says Nancy Loeffler, MHA, BSN, RN, ACM, CCM, senior director of care coordination and clinical practice at Inova Medical Group in Falls Church, VA.
The program’s outpatient case management and care coordination was initiated as part of a patient-centered medical home, Loeffler says.
“We started out with nurse navigators who are care coordinators,” she says. “We did data analysis and found the low-hanging fruit, which was diabetic patients in critical care with neuropathies.”
After reviewing charts, nurse navigators found there were opportunities to improve care and outcomes through education and follow-up, Loeffler says.
A typical caseload could range up to 300 patients, says Elena Rushing, RN, BSN, CNRN, nurse navigator for Signature Partners/Inova Medical Group.
“Most of the patients are diabetics who have A1c [glycated hemoglobin/blood sugar] tests of over 9,” Rushing says.
About 30 patients she follows have other chronic illnesses, including congestive heart failure, asthma, and coronary artery disease. And she follows some high-cost patients who use the emergency department frequently.
“I work in five offices; two are family practices, and all are under the patient care medical home,” Rushing says.
Anecdotally, case management appears to be working: Diabetic patients receiving case management have shown improvement on the chief measures of disease control, Loeffler says.
“In the first sixteen weeks, we saw that 80% of the 534 patients had dropped 5.5 points in their A1c test.”
With those results, the organization expanded the program, hiring two more nurse navigators, she adds.
Loeffler and Rushing offer the following look at how the program works:
• Obtaining physician buy-in. When the care coordination program began, it met with some physician resistance for the first few months, Loeffler notes.
But after Loeffler met with doctors and explained what the program would do, she began to build trust and a relationship. The true buy-in occurred when they saw case managers at work and learned of the positive outcomes, she adds.
Physicians and their staff now gladly welcome the care coordinators: “When they walk into the building, they hear, ‘The angel is here!’” she says.
The physician office staff make care coordinators feel welcome, Rushing says.
“Everyone is very excited that we’re there,” she says. “I really feel like people want us in the offices and are grateful we’re there.”
• Dedicated space and times. When Rushing isn’t meeting with patients, she has a space in each doctor’s office where she can use a computer and make calls from her work phone.
“That way, I can work in the office and not keep moving around, and I appreciate that space,” she says.
Case managers meet with patients in the physician office conference rooms, spending 15 to 30 minutes with patients, Loeffler says.
Rushing makes appointments with patients, going over their diabetes education packet, which covers basic information about their diet, symptoms of low and high blood sugar, and medications.
“I show them how their plates should look when planning meals,” Rushing says. “I try to not overwhelm them in the first sitting, and I answer a lot of questions.”
When Rushing doesn’t have appointments scheduled, the doctor might give her an on-the-spot patient referral.
For instance, the physician might have a problem with a patient who needs to be on daily medications, but cannot afford them. Rushing would meet with the patient and discuss the problem, finding resources as needed, she says.
“In all five offices I go to, the doctors know I am there on that day,” Rushing says. “It helps everyone to know the nurse navigator will be there.”
• Clarify what case managers do. It’s possible that a busy doctor’s office could begin to rely too heavily on nurse navigators, seeing them as an extra set of hands, Rushing notes.
“Nancy was very firm in making sure that we were not doing those things,” she says. “The offices are very aware of that and they know that.”
Nurse navigators are there to help patients with health education and to assist them with any social needs they have that act as barriers to their maintaining optimal health, Rushing says.
“A lot of patients want to be listened to, and if I were walking back and forth, trying to help the office’s nurses with blood pressure, then I wouldn’t be able to give patients 100% of my attention,” she explains.
• Access EMRs. Through EMR access, Rushing could review patients’ charts, hospital records, and outpatient charts.
“I can keep up with them and find out how they’re doing when they’re in the hospital and when they’re discharged,” Rushing says.
• Fridays for staff meetings: All nurse navigators cover five to six offices each day of the week except for Fridays, which is when they meet at the main office to discuss the week and agenda items, Rushing says.
“For example, one thing I brought up a month ago was that I needed some assistance with a patient I had,” she says.
“I discussed a patient from where we were doing transitional care management calls, transitioning patients from the ER or hospital and discharging into the community,” Rushing explains. “This patient was going to the ER frequently, two to three times a month, and one of my thoughts was that this patient is going to the ER a lot. Is there something I could do to help with that?”
Rushing’s peers have her ideas of strategies to help keep the patient out of the ER. One idea was to have the patient visit the Inova infusion clinic for hydration services. “One of the reasons the patient was going to the emergency room frequently was because she had gastroparesis and needed to be hydrated.”
Taking the advice, Rushing got the patient connected with the infusion clinic.
“The patient started going there, receiving services, and has not been back to the ER for the past three months,” Rushing says.
An outpatient case management and care coordination program targeted a population of people with diabetes to improve quality of life and medical care.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content