Ten Pearls on Starting an RN Care Management Program in Your Practice

Care management is increasingly being defined and discussed in the literature.(1-3) (The term often is used interchangeably with the term care coordination.) Care management targets a practice’s most medically complex patients in an attempt to reduce hospitalizations and improve health outcomes for those patients. This service typically is provided by an RN, although clinical pharmacists and behavioral health staff increasingly are becoming involved in providing the service as well. Care management and care coordination have been shown to reduce costs to the healthcare system and are increasingly seen in practices following the Patient-Centered Medical Home (PCMH) model.

In this article, we offer 10 lessons we have learned as we embedded RN-driven care management in our practice over the last four years.

1. Decide on a uniform way to risk-stratify your entire patient panel.

Patients in a typical primary care practice range from young and healthy people to those with multiple chronic medical issues. All patients need some form of care management. The young and healthy patients mainly need outreach around overdue health maintenance, such as vaccinations and Pap smears. These preventive activities do not require an RN-level employee to perform; they often are very effectively handled by a medical assistant–level panel coordinator. RN care management should be reserved for more complex patients, who can be identified by diagnoses, input from their primary care provider (PCP), or claims data. We have found that using a multimodal approach to risk stratification, which includes diagnoses, PCP input, recent emergence department and hospital utilization, and use of high-risk medications such as warfarin, most effectively identifies our highest-need patients. We also find that addressing risk stratification twice per year helps keep the list of highest-risk patients current. The process of enrolling a patient in and graduating him or her through RN care management should be fluid and not defined by a specific length of time, because patients’ responses to medical conditions are variable.

2. Communicate clearly to both patients and their PCPs that care management is a proactive partnership.

In implementing our care management program, we found that RNs often were asked to provide care management for patients whose real need was care coordination. The typical clinic day is a series of “active fires” (e.g., the fainting patient) that need to be put out, before the “smoldering” issues (e.g., care management for patients with chronic disease) can be addressed. Clinics need clinic RNs to address active fires and RN care managers to work to contain and suppress the embers. This analogy highlights how care management and care coordination are two distinctly different activities. Care management is proactive outreach and requires an active partnership with the patient to set health goals. These goals may be different from, for example, “achieving an A1c lower than 7”; the goal may be to “be healthy enough to see my daughter graduate from high school.” Care coordination may involve securing resources such as home oxygen or physical therapy services at home, or helping coordinate care of a patient with an urgent health concern with the hospital. Although many care-managed patients do concurrently need care coordination, care coordination activities do not necessarily require active goal setting on the part of the patient in order to have their needs addressed.

RN care management is not a concierge service for difficult patients who have overwhelmed their PCP. RN care managers are not tasked with changing patient behaviors; only patients can do that. Care management consists of assessing the patient’s motivation to change, educating the patient about healthy lifestyle behaviors, leveraging the patient’s family and community resources, and promoting self-management of chronic conditions. Care management is working with the patient instead of for the patient.

3. Invest in training for RN care managers.

RN care management works best when there is RN staff dedicated to provide this service. In a busy clinic, if care management is not a protected role, it will be the last priority and a task that gets done at the end of the day—if there is any end of the day left. We found it helpful to build the care manager skill set by uptraining our RN staff on patient engagement, health coaching, and collaborative goal setting. Many opportunities for continuing education in these arenas are locally accessible and often are advertised to clinic leadership. Several of our RN care managers worked to receive national certification from the American Academy of Ambulatory Care Nursing (AAACN) for Care Coordination and Transition Management, which continues to enhance the work they do for patients.

Although formalized training is available, care management is not a series of tasks with a script to follow. A successful, change-making RN care manager must be a “terrier who won’t let go of the pant leg.” He or she must challenge the norm; be persistent; exhaust alternatives; and not take no for an answer easily. If a high-risk patient needs to be admitted to a skilled nursing facility, and the admission coordinator denies it, stating the patient must first have a three-night hospital stay, challenge this system. The care manager will call the patient’s insurance company, the discharge coordinator from the patient’s previous admission, the patient’s Aging and Disabilities case manager, or a different skilled nursing facility. The clinic and the hospital are “boxes,” and the RN care manager needs to think outside of them.

4. Embed RN care management within the PCMH.

RN care management is best introduced to the patient through a “warm hand-off” from the PCP. It gives the program and care manager instant credibility and reinforces the strength of the interdisciplinary medical home care team. Patients are busy or overwhelmed with their health issues, and they may not pay attention to or understand RN care management if it is initiated through a phone call or letter.

RN care managers should be visible and embedded in the clinic, not located remotely or only available to patients by phone. The care manager works most effectively and efficiently when he or she works alongside and in collaboration with the primary care provider. The RN care manager in the clinic understands the resources available within that setting, the health system, and the community. He or she can “piggyback” on PCP visits to go more in depth with a patient or family beyond the 15-minute primary appointment. This helps patients identify and trust the RN care manager whom they see with their primary care provider.

We also found that creation of a clinic-based policy around care management was helpful for clinicians, RNs, and other staff to refer back to. A written policy may help reinforce to staff and clinicians which patients are most appropriate to receive services. It also provides the opportunity for all members of the care team to refer a patient to your RN care management program.

5. Consider actively discussing care-managed patients during team meetings.

We work in “protected time” during our clinic team meetings to celebrate successes or discuss specific care-managed patients in greater detail. For the more challenging patient cases, these meetings provide an opportunity for multidisciplinary input from front desk staff, medical assistants, other clinicians, and behavioralists to work through roadblocks collaboratively. Our group sessions have come up with creative solutions or resources that may benefit the entire clinic. Another possibility is a daily huddle between the PCP and the RN care manager, to plan for any needs before clinic sessions begin. This can enhance the scheduled patient visit with his or her PCP.

6. Ask yourself whether the activities assigned to your RN care managers fulfill the Triple Aim.

In the era of the PCMH, our activities should aim to fulfill Berwick’s Triple Aim: increased patient satisfaction; increased quality; and decreased cost.(4) Our RN team found that reflecting upon patient success stories using the Triple Aim is an important measure of success of the RN care management program. These metrics also are important not only from a PCP’s perspective, but also from a practice perspective. For example, a patient’s family may think the patient needs to return to the emergency department to have her nasogastric tube removed, but the RN care manager can arrange for a home health RN to remove the tube instead. This intervention achieves two of the Triple Aim points: less hassle for the patient (increased patient satisfaction) and a more efficient use of resources (cost reduction).

7. Hospital and emergency department followups present a structured way of introducing RN care management into your practice.

Reduced hospitalizations and emergency department visits are a direct measurement that leads to decreased cost to the healthcare system. Generating reports on who has been in the hospital in your practice presents an opening for an RN care manager to reach out to the patient on behalf of a PCP. He or she can inquire on the patient’s status since discharge and identify what needs the patient may have. In our practice, we optimize the 48-hour hospital followup contact. Assigning this task to a scheduler or medical assistant may result in an appointment. However, an RN care manager can perform a thorough assessment, provide patient education about medications and lifestyle behaviors, detect problems, bridge the gaps from hospital discharge to home, and make a follow-up appointment.

In our practice, the discharge plan is reviewed and clarified with the patient, and gaps in care are addressed (e.g., need for referrals as an outpatient). The outreach call often elicits warning signs and symptoms that are important for the clinician to note during followup visits. For example, our RN care managers have discovered issues such as deep venous thrombosis after orthopedic procedures; a patient who did not have a cardiologist after a five-vessel coronary artery bypass graft; and an anticoagulated patient discharged on a cocktail of ciprofloxacin/metronidazole without a scheduled International Normalized Ratio test. Hospital medications and outpatient medications also are reconciled during the outreach call. Finally, it is an opportunity to introduce or reinforce the RN care manager as a member of the patient’s care team.

8. Create templates and shared notes around RN care management for common diseases such as diabetes, congestive heart failure, and asthma.

Templates for chronic disease do not have to be exclusive to adult medical conditions. If, for example, you have a significant pediatric population in your practice, you might want to create a template for pediatric asthma. If you have a significant obstetric practice, you might create a template around gestational diabetes. These templates can extend into mental health diagnoses as well, which also allows the natural involvement of a behavioral health specialist in the care management practice. Although we started with templates as a guide, we found that simplifying our note to include a Goals of Care and Self Management Plan was most effective for our group (Figure 1). It is important to note that even with the use of templates, those templates should be customizable to each patient, which may lead to a practice using a broader template.

Figure 1. Sample RN care management template. LE, lower-extremity; SOB, shortness of breath.

Dramatic changes in health status serve as “wake-up calls” for people to make healthy lifestyle changes. This is a good time to introduce the RN care manager to help coach or guide the change. Examples include a new diagnosis of congestive heart failure, diabetes, or pregnancy. At these natural inflection points, the patient’s health trajectory can be altered with the right support.

9. Consider community activities as a way for RNs to expand upon their one-on-one care management services with patients.

A schoolteacher designs education to reach a group of students—he or she doesn’t go from desk to desk repeating the same information. Students also learn a lot from each other, without the teacher’s involvement. Engage high-risk patients in group visits. For example, our RN care management team hosted an afternoon session that explained to a group of high-risk patients the importance of having an Advanced Directive. Help people complete the form right then and there. Imagine avoiding just one protracted ICU stay that goes against the patient’s wishes, because there is already an Advanced Directive in his or her chart. These group visits can lend themselves to physician involvement and group visit billing opportunities as well. Finally, they can allow for meaningful involvement of a practice outside the setting of its normal clinical activities.

10. Think actively about ways your practice might pursue funding for RN care managers.

We were fortunate to participate in a Medicare initiative called the Comprehensive Primary Care Initiative that allowed our practice to receive a per-member per-month payment to implement activities such as RN care management. Billing for chronic care management codes via Medicare would be an alternate way for a practice to support having an RN care manager. Transitional code billing also may help support RN care manager activities and capture additional revenue when patients are seen for post-hospital followup visits. Exploring grants would be yet another avenue. Evidence of improved outcomes, improved patient satisfaction, and decreased costs may also provide a strong argument for funding such roles in your institution.

References

1. Craig C, Eby D, Whittington J. Care coordination model: better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011; www.ihi.org/resources/pages/ihiwhitepapers/ihicarecoordinationmodelwhitepaper.aspx .

2. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363:2611-2620.

3. The Value of Nursing Care Coordination: Executive Summary. June 2012; www.nursingworld.org/ccexecutivesummary.

4. Berwick D, Nolan T, Whittington J. The Triple Aim: care, health, and cost. Health Affairs. 2008;27:759-769.