By Melinda Young
A Federally Qualified Health Center (FQHC) that invested in a registered nurse care coordination (RNCC) program in a primary care setting found the position provided a valuable service and was cost-effective.1
“Chronic disease management is very complex and can be difficult for patients to self-manage, especially when living with multiple chronic conditions,” says Jessica Alicea-Planas, RN, MPH, PhD, an associate professor at the Egan School of Nursing and Health Sciences at Fairfield (CT) University. “We wanted to look at the expanded role of the RN as a registered nurse care coordinator to see if this different role of RN would facilitate more patient-centered care and better health outcomes.”
Alicea-Planas and colleagues found patients living with diabetes and hypertension recorded improved biometrics when they were assisted by the RNCC program. Plus, the program’s cost was both self-sustaining and revenue-producing.
“We looked at data from an FQHC that had created this position and put seasoned RNs into these positions,” Alicea-Planas says. “These were not positions where a brand-new RN got plopped into it. These were seasoned nurses who understood the community in which they worked and understood the struggles their patients were dealing with.”
RNCCs address social determinants of health, which are important for influencing health outcomes, Alicea-Planas says. The expanded care coordinator role focused on targeted education and identifying what patients really need.
Targeted Education
A chief difference was how the RNCC moved away from the one-size-fits-all model of health education. Care coordinators often give patients a handout on their disease and expect them to learn from this standardized format, Alicea-Planas notes. “We don’t always take into consideration the patient’s background or their socioeconomic background,” she adds. “Sometimes, we don’t even assess whether the patient can read before giving them a handout.”
With targeted education, RNCCs understand of all the challenges patients might face as they try to manage their condition. For example, the RNCC working with a patient who is food insecure will talk with them about nutrition but note the patient is receiving the bulk of his or her food from a public pantry. Or a patient with diabetes might miss annual visits with an ophthalmologist and a podiatrist.
“The RNCC would realize transportation was an issue and get a community health worker to set up transportation to the ophthalmologist,” Alicea-Planas says. “We’re all very busy, and sometimes these little details are missed. The patient is the one who ends up suffering, or the patient is noncompliant.”
Placing experienced nurses in the RNCC role helps with the program’s success. It also helps for the FQHC to provide nurses with training on how to provide targeted health education and how to work with patients on goal setting and behavior change. “The RNCCs were given multiple interviewing techniques,” Alicea-Planas adds. “They were given some additional tools to help them be able to provide better health education during one-to-one visits.”
Time with Patients Is Valuable
An essential part of the RNCC program is to give nurses additional time to spend with each patient. “The RNCCs have their own schedules where patients are given half an hour or an hour flat,” Alicea-Planas explains. “They have dedicated time to work with the patient.”
The RNCC visits are scheduled separately from the patient’s visit with the physician. “The biggest thing they were given is time,” Alicea-Planas notes. “[Lack of] time is a big reason why things aren’t paid attention to.”
Providers referred RNCCs to high-risk patients. These included diabetic patients with high A1c levels and those who struggled with controlling their blood pressure. The RNCC model would work with patients with a wide variety of health conditions, but the FQHC wanted to focus primarily on diabetes and hypertension, Alicea-Planas says.
To assess the RNCC role’s effect on patient care, Alicea-Planas and colleagues performed a retrospective case study to determine whether patients’ hemoglobin A1c and blood pressure levels changed when they routinely visited an RNCC.
“We were looking for decreases, perhaps to show that this was improving health outcomes,” Alicea-Planas says. “We also wanted to see if it was cost-effective because RNs are not cheap.”
Since every healthcare change needs a quality and economic benefit, investigators also studied whether the RNCC visits were revenue-producing. “They could bill Medicare and Medicaid as long as a diagnosis and a connection with a provider already existed at the health center,” Alicea-Planas explains. “They couldn’t see a person who was not a patient at the health center.”
RNCCs would bill under specific nursing codes and receive reimbursement for the special nursing visits. “This started happening before COVID, so it was not a pandemic-related special coding,” Alicea-Planas says. “We also looked at roughly how much they were reimbursed for a visit, how many patients they were averaging in their schedules, and how much their salaries cost. We ran some numbers to see whether the FQHC was losing money.”
There were positive results in both quality and economic benefit. “We found a significant decrease in hemoglobin A1c levels, and we also found a significant decrease in systolic blood pressure levels,” Alicea-Planas notes. “But there was no change in diastolic blood pressure or BMIs [body mass index].”
Alicea-Planas and colleagues also learned the cost of the RNCC position was revenue-producing and could become a self-sustaining role. This coordinator had to be a registered nurse — not an LPN — for the facility to bill for the service.
The RNCC appointments were held at multiple FQHCs. RNCCs also would call patients and provide follow-up, but the billable visits were held in-person.
The care coordination team included community health workers, who were experts on the community resources patients may need. They can help patients with social determinants of health issues. Seasoned RNs who really know their communities is also important to providing patients with the best care possible.
“When you have nurses working in community health, we become very well aware of how to connect patients with resources,” Alicea-Planas says. “We’re very good at finding something, saving it, sharing it, and saying, ‘This could be useful for our patients if we have patients who are food insecure or uninsured.’”
As organizations create RNCC positions, they should remember there is a learning curve with referrals. At the FQHC, some providers did not make referrals because they were unaware of the benefits this could provide their patients.
Since the program evolved and RNCCs initially had to balance their workloads as they built their caseload, there was a bit of struggle in balancing the new role with their other responsibilities.
“One of the things that we heard from RNCCs was they would sometimes get pulled in to work someplace else that was short-staffed,” Alicea-Planas says. “That was a hard balance for them in the beginning.”
As time went on and the referrals increased, RNCCs worked full caseloads and were pulled away less.
REFERENCE
- Alicea-Planas J, Burger S. Integration of the registered nurse care coordinator role in a federally qualified health center. J Ambul Care Manage 2023;46:194-202.
A Federally Qualified Health Center that invested in a registered nurse care coordination program in a primary care setting found the position provided a valuable service and was cost-effective.
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