Need to network with Care Coordinators who deal with Medicare patients in private practice

SHGR, MSN, RN, CNS · Dec 24, 2014

I do a lot of this, particularly Medicaid (with a little Medicare and some private insurance in there too). Are you mostly telephonic? Transitions of care? Face to face in clinic too? Home visits? Do you do your own case-finding or do you have a system that alerts you to people who need coordination?

I guess I have been looking for someone to talk to too. :)

asabau87 · Dec 29, 2014

The practice that hired me is new to this and want to have a Care Coordinator on board.They do not have any software that would help me with that just yet.I am doing mostly telephonic,also transitions in care.No Home visits or clinic.I am trying to get started but all i am working with right now is AllScripts.The practice is open to purchase a software.which one do you use if any?

Piggles10 · Jan 10, 2015

I am interested to hear how this goes for you. I am starting/ developing a new position that has been called: Care Transitions Coordinator, Case Manager, and Patient Navigator. I have been told to reach out to resources and develop this. I am very excited about the open possibilities, but need to get organized quickly. The main point of my position is to reduce readmissions. I am open to any suggestions.

SHGR, MSN, RN, CNS · Jan 10, 2015

We use Crimson Care Management from the Advisory board company to manage some of these aspects (transitions and complex care). It sends real time email alerts for transitions which I love. It may not be appropriate for your situation though. We also use software called i2i that allows us to easily generate registries and reports within the practice.

asabau87 · Jan 26, 2015

Yea, I am in the same position. Its a great opportunity for growth, however lots of brainstorming. I've got the TCM figured out with not having any Care Coordination software yet. It took me about a week to figure out where the issues were within the practice. I took it from there and built upon it. Some providers are not very happy with the changes because they have to document according to certain guidelines. How has your road been so far? What challenges are you facing?

asabau87 · Jan 26, 2015

Is anyone going to the Care Coordination Summit in Baltimore May 4-6 I believe?? I would love to network :-)

2Bretired · Mar 28, 2015

I am working in a large health plan that does Care Coordination/Management within a large clinic. We work with PCP to help manage their patients, follow patients being discharged and using motivational interviewing to help educate and make changes. Our population is largely medicare and d/t Obama care changes we now have lots of Medicare members/patients to enroll as well. We have well developed computer system, CCMS currently but are planning to switch over to a different computer system in the next year. Our patients are populated through a data base to identify the heavy users and those with the top 5 chronic conditions, COPD,HTN,HF,Diabetes Hypercholesterimia. We are doing in clinic, in home and cold calls. It is very challenging work and we are charged with only having an open case for 90 days. Finding this to be a daunting task! BUT- would never go back to hospital nursing again. I was a Triage/staff nurse for 10 yrs in the Internal Med department (35 providers) prior to the CM position I have now. Wish I was going to the Summit in May, of course, no one wants to pay for staff to go anywhere these days! :)

asabau87 · Apr 2, 2015

I am working in a large health plan that does Care Coordination/Management within a large clinic. We work with PCP to help manage their patients, follow patients being discharged and using motivational interviewing to help educate and make changes. Our population is largely medicare and d/t Obama care changes we now have lots of Medicare members/patients to enroll as well. We have well developed computer system, CCMS currently but are planning to switch over to a different computer system in the next year. Our patients are populated through a data base to identify the heavy users and those with the top 5 chronic conditions, COPD,HTN,HF,Diabetes Hypercholesterimia. We are doing in clinic, in home and cold calls. It is very challenging work and we are charged with only having an open case for 90 days. Finding this to be a daunting task! BUT- would never go back to hospital nursing again. I was a Triage/staff nurse for 10 yrs in the Internal Med department (35 providers) prior to the CM position I have now. Wish I was going to the Summit in May, of course, no one wants to pay for staff to go anywhere these days! :)

I would love to connect with you to learn more about how have your flow set up in regards to care coordination. Anything would help.:-)

Andreia

2Bretired · Apr 3, 2015

I started work as a CC in 2012 in Lg clinic in WI. We had Medicaid,Medicare and HMO patients. We did 60% Telephonic, 40% F2F in clinic, we did not do home visits but we did do Transition care in the our hospital. Our clinic has a phenomenal EMR system and they came up with a data base to assist with finding the patients that had top 5 disease states and who utilized the ER and Hosp a lot. Throughout our whole clinic system we had 45 CC in all our centers. I was located at the main campus and we had 10 CC in Internal Med and Fam Practice for about 45 providers, we also are a teaching facility so we had about 20 residents that we managed some of their patients as well. Unfortunately we are a Not for Profit clinic and our funding for the CC program was cut last April and all 45 of us were let go. Attached to our clinic is our own Health Plan and they had a small handful of care 'managers' that did disease management and care management. Because the providers in the clinic had embraced the CC program so well, they wanted something put back in place in the clinic and the Health Plan restructured a bit, hired 2 of us previous CC and we are now back in the clinic on a much smaller scale and now we are Care Managers! There are 8 of us doing what 45 did previously! The Health plan has an even better system for case finding and of course it always comes down to the "super-users" and medicare members (no longer patients, in the Health plan they are members). The only Medicaid members we outreach are the ones that have purchased something with us through the new Market Share. We just started doing home visits along with CM (case Management) and we have 3 separate nurses that strictly do TC, usually only 2 calls and they are done, our TC program in CC at the clinic was 6 weeks of following, so it is much more streamlined. I have about 45 members that I am working with right now, and the goal is to only keep them on your "list" for 90 days. Struggling with that small number right now, really only touch them about 4 times and we are charged with limiting our calls to about 20 minutes and we are trying hard to implement Motivational Interviewing into our skill set! Don't make much impact in 20 minutes and multiply that by 4-5 calls and you really only talk to them for a total of 2 hours! Hard to elicit permanent change in just 120 minutes! That is my update, would love to hear more how other areas are managing this and if this any good conferences to attend, unfortunately, none of us are going to the summit in Baltimore, it sounds wonderful but again, no one wants to pay for these great learning opportunities anymore! :)

2Bretired · Apr 3, 2015

Piggles10- that is a tall order to organize all of these! We have 2 Patient Navigators in our Health Plan and 3 TC Coordinators and 8 Case Managers (care managers). Reducing re-admissions is huge but requires some cooperation from the ER! We find ER docs tend to admit for things that really could be managed as outpatient. We call some of the patients that come in "Super Users" because they have Medicaid and pay nothing so it works for them to go to the ER for a sore throat or bump on the knee! I believe this is not as big an issue in other parts of the country but in Rural midwest it is. You will definitely need a IS support, not sure what system you have for EMR but that is key, having access to the medical record and communication with the hospital(s) regarding admissions. Our goal is to contact anyone discharged within 24-48 hrs, think this pretty standard. Good luck, happy to help if I can.

2Bretired · Apr 3, 2015

Hi- I would be happy to network! This is a tough job but can be very rewarding.