By Melinda Young
Indiana’s Medicaid program administrators found value in embedding nurse care coordinators in primary care practices (PCPs) to address social determinants of health and transitional care issues in a population of children with complex medical issues.1
This is how the complex care coordination collaborative works:
• Define target population. Care coordination projects are costly. Providers must select populations that would benefit most. In this case, the target population was children with medical conditions that affected three organ systems and required three specialists for their care. Each child saw at least one PCP and three specialists involved in their medical care.
“The primary care coordinator helps them work well together, and the care coordinator is a registered nurse,” says Mary R. Ciccarelli, MD, the Morris Green professor of pediatrics and a professor of clinical medicine at the Indiana University School of Medicine. “We have a 97% acceptance rate of families wanting to be in the program, and 90% stay in the program.”
• Find providers who are interested in the program. “We approach practices and say, ‘Are you hungry to have this kind of support in your practice?’ If they say ‘yes,’ we help them identify a nurse or hire a nurse to be a care coordinator,” Ciccarelli says. “It’s funded through Medicaid dollars, and we train them. We suggest what job requirements they’re looking for and what experience is needed, and we take it from there.”
Some practices promoted an employee from their office, and others hired someone outside their office. “I don’t care which happens, but the training is slightly different if they’re new to the practice,” Ciccarelli adds.
• Train care coordinators. “Primary care providers hire the care coordinators,” Ciccarelli says.
Training helps care coordinators become effective and efficient. “Our hypothesis is that with a little more structure, people get up to speed a little faster,” Ciccarelli adds.
The three-phase training starts with a two-week orientation of 12 to 15 hours. Then, there is a six-month, high-intensity curriculum of three hours per week. It is followed by a longitudinal learning collaborative of three hours a month.
“It is a lot of training,” Ciccarelli says. “Proving that it’s worth it economically is not a small task, but that’s what we’re working on now.”
• Teach care coordinators how to think like social workers and case managers. Since the care coordinators already come from strong medical backgrounds, much of the training focuses on how they can find creative solutions to patients’ social determinants of health.
“How can someone get equipment if the insurer won’t pay for it?” asks Lorena Flaa, BSN, RN, nursing care coordinator manager of the Indiana Complex Care Coordination Collaborative (IC4) at Indiana University School of Medicine. “What’s available out there — not only locally, but national?”
The model teaches care coordinators to find resources in their communities to connect patients and families with solutions, says Natasha Guffey, LSW, MSW, program director of IC4.
For example, one care coordinator helped a family deal with a house fire that left them without basics, such as food and clothing. The care coordinator helped connect the family with a church and ensured they had a place to stay while they figured out their insurance and long-term housing plan.
“The care coordinator talked with the family about having their medications and supplies delivered to where they were staying temporarily,” Guffey explains. “The care coordinator helped them reschedule appointments because they were going through trauma. Having one person they could go to for help with care coordination was the biggest highlight of what the family needed at that time.”
Care coordinators can call local organizations and charities to see what they can help with and determine their limitations and financial eligibility requirements. For example, a patient’s family may need some construction changes to their home to accommodate their child’s wheelchair.
“How do I use community-based services that may not be covered by traditional insurance payment methods?” Ciccarelli asks. “How do I brainstorm and get a ramp built by a church group or an Eagle Scout?”
The family might not qualify for government funding for the ramp, but if their child is in a wheelchair, they may need one. It is possible to find a local scouting troop that includes someone who needs an Eagle Scout project, and building the ramp would work well. Using local churches, scout troops, and volunteer organizations to help is a creative solution. “Knowing your community is important,” Ciccarelli notes. “Care coordinators need to know how to begin to do that.”
They need to find these resources before a need arises because they do not have time to spend all day trying to figure it out, Ciccarelli says. This is where training helps. “You need someone to help you on how to do that,” she adds. “You can imagine the difficulty if you were just hired, and how long it would take you to figure this out.”
• Emphasize organization, communication, and collaboration. “We have a curriculum-delivered didactic on time management that’s talked about in the first week of orientation,” Flaa explains. “It discusses the importance of time management, developing systems, and how to work effectively with 100 families and not just the 10% who contact you most.”
Time management is especially important as care coordinators learn about their families and find that some often are in crisis mode and need a lot of attention. Care coordinators must learn how to not get lost in the weeds of handling a handful of cases when every family needs some regular attention.
“It’s important to have a system and way of tracking to see that all families are being contacted and have their needs addressed,” Flaa explains. “Our project is a quality improvement project. We have quality indicators that have set goals for each care coordinator to meet, and we give them the resources they need.”
For example, the key quality indicators include contacting every family at a minimum of every 90 days. They also need to maintain a registry of 100 patients and create a shared plan of care for each patient and family.
The shared plan of care details the patient’s medical history, specialists, appointments, family health history, and personal details. Care coordinators complete the shared plan of care for each child and conduct a reassessment every six months.
“Every 90 days, they assess how they’re doing and make sure they don’t have any needs,” Flaa adds. “It’s super hard work.”
This means care coordinators conduct an average of four shared plan of care reassessments every week, and they contact eight unique families per week. “Some families are in contact a lot more frequently than that, especially if they’re in need and in crisis,” Flaa says.
The project has continued for more than three years. Several care coordinators have maintained a 100-patient caseload and are handling it well, Flaa notes. Leaders keep tabs on how well care coordinators are managing the workload and stress.
“We have a didactic, called Self Care: How to Care for Yourself,” Flaa says. “This job is hard, and they give so much to their families.”
Flaa meets with new care coordinators once a week for the first six months, then once a month. She asks what they are struggling with. She also holds a one-hour Zoom session with all of the care coordinators.
• Improve patients’ lives. One way to make patients’ and families’ lives easier is grouping services when a child is undergoing anesthesia for a procedure.
“It’s one of the big things that’s the hardest for care coordinators to do, but it is really great for patients,” Flaa says. “That has happened quite a few times in our program.”
For example, one child needed dental work and a separate imaging procedure. The care coordinator worked with providers to perform the dental work under anesthesia, followed by the imaging, while the child was still under. The care coordinator even had blood drawn for lab work while the child was sedated.
“The child is only under anesthesia once instead of twice, which can be dangerous,” Flaa notes. “It’s easier on the family and child, and it’s cost-effective.”
Grouping procedures that require anesthesia and adding lab work whenever the patient is under anesthesia is efficient, safer, and beneficial to the complex pediatric patients. The children’s hospital provides dental services, making the grouped services possible.
While grouping services is better for pediatric patients, it is a challenge for care coordinators who have to orchestrate the timing of the three separate services, call all the practices and providers to coordinate, and then find the place and time that will work for everyone.
REFERENCE
- Indiana Complex Care Coordination Collaborative. Indiana University School of Medicine. 2023.
Indiana’s Medicaid program administrators found value in embedding nurse care coordinators in primary care practices to address social determinants of health and transitional care issues in a population of children with complex medical issues.
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