Aetna, Marshfield Clinic, Advocate Health Partners, Capital District Physicians' Health Plan — just a few early adopters in the industry taking the lead from Geisinger Health System and embedding case managers in physician practices. In just a short time, these care management collaborations have greatly improved outreach and coordination for high-risk populations and generated some promising ROI — as much as 2:1 in one early pilot — as well as impressive spikes in practice efficiency, volume and quality of care.

Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination examines two promising pilots in embedded case management: Nurse Navigators working alongside physicians in Bon Secours Health System's Advanced Medical Home program, and Nurse Case Managers at the heart of CDPHP's Enhanced Primary Care effort.

This 50-page resource is a primer on embedded case management, from the selection and training of the case manager to preparation of practices for the case manager's arrival to a description of more than 15 tools, protocols and workflows in use in this retooled care delivery model.

Following in the footsteps of Geisinger Health System's ProvenHealth Navigator model, both initiatives are driven by the same core desire to move from a provider-centered to a patient-centered model. This restructuring aims to utilize all staff members at the highest levels of licensure, reduce waste and improve care quality and access for patients and health plan members. Both organizations say the approach is helping to reduce hospital readmissions and ER visits and tighten transitions of care for high-risk patients.

The 50-page Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination documents development and rollout strategies and results from two similarly sized pilots of embedded case management:

Bon Secours Health System Advanced Medical Home: Robert Fortini, Bon Secours VP and chief clinical officer, describes how RN nurse navigators are helping to transform care during a three-phase Advanced Medical Home program. Implementing retooled workflows, nurse-driven protocols and selection of homegrown tools and indices, Bon Secours hopes to effectively double the capacity of its 350 physicians in 80 Virginia locations while improving the health of its patient population.

CDPHP Enhanced Primary Care: New York-based CDPHP has enlisted private practices to pilot its two-part Enhanced Primary Care program. Lisa Sasko, MA, MBA, CDPHP director of clinical transformation, and Charlene Schlude, CDPHP director of case management, share details on a pilot that encompasses both payment and practice reform. Ms. Sasko covers new reimbursement strategies, PMPM savings and quality gains generated by the effort, while Ms. Schlude details the philosophy, framework and practicalities of embedded case management, including schedules, case loads, hiring, program costs and lessons learned.

Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination also provides details on:

Three key reasons to pursue clinical transformation; Applying division of labor principles to a physician practice; Readying a practice to receive case managers; Guidelines for embedded case manager skills, selection, funding, case loads and job responsibilities; Target populations and member stratification strategies; Contributions of pharmacists to CDPHP's Enhanced Primary Care effort; Benefits of home-based telemonitoring for patients with end-stage renal disease (ESRD); Guidelines for integration of primary and behavioral health in a physician practice; Lessons learned on practice selection and staff selection for embedded case manager pilots; Value-added services available to nurse case managers to support home visits and home case management; and much more.

PLUS the Q&A chapter answers more than 30 questions on the patient-centered activities of these two organizations.

Table of Contents:

• Bon Secours Nurse Navigators Transform Primary Care
  • Using Principles of Division of Labor
  • Workflows of a Rich Staffing Model
  • Standard Protocols
  • Responsibilities of the RN Embedded Nurse Navigator
  • Patient Severity Index
  • Metrics to Measure Success
• CDPHP Embedded Case Manager Crucial to Clinical Transformation
  • Enhanced Primary Care Akin to Medical Home Model
  • Savings by Cost Categories
  • Philosophy of Embedded Case Management
  • Practice Selection Criteria
  • Impact of Practice Transformation
  • Responsibilities of the Nurse Case Manager
  • Role of the Pharmacy in Enhanced Primary Care
  • ESRD Populations
  • Outcomes, Future Plans and Lessons Learned
• Q&A: Ask the Experts
  • Funding RN Case Managers
  • Training the First Nurse Case Managers
  • Productivity Benchmarks for Embedded Case Managers
  • Prehuddle Reviews
  • Cost Savings from Case Managers
  • Physician Incentive Models
  • Patient Risk and Acuity Levels
  • Case Management Certification
  • Relative Readmission Index
  • Evidence-Based Teaching Tools
  • Factoring in Observation Stays
  • Primary Care Partnerships
  • Payor Incentives for Case Management
  • Translating Model to Specialist Practices
  • Readmissions Metrics
  • Bon Secours Demographics
  • Prioritizing Case Management Resources
  • Case Management Outreach
  • MyChart Patient Portal
  • Payment Models
  • Skills for a Successful Case Manager
  • Hiring the Right Embedded Case Manager
  • Care Plan Management Tools
  • Health IT and EHRs in the Practice
  • CDPHP Demographics
  • Case Manager Communication Tools
  • ROI Methodology
  • Expanding the Touch of the Practics
  • Measuring Member Satisfaction and Service
  • Cost to Patients
• Glossary
• For More Information
• About the Presenters