2Bretired

asabau87, you have taken on a tough job to handle alone! Identifying and stratifying the patients is important. Right now our program ranks them by acuity and the 5 chronic diseases, takes into account hospital and ER visits as well as $$ for care. 5 is the highest and they of course are the hardest to improve, we focus on anyone 2.5 and above on our lists. Because we are a Health Insurance we have great IS support to pull data from our claims. We also work with Gaps in care, if members/patients have not had A1c, diabetic foot exams, BP checks, colonoscopies- we engage them to have these done, that is part of being an ACO clinic. After you identify the patients you need to work with we "target them" in our program and start on the Assessment. It is absolutely crucial to have a good working computer program that interfaces with a medical record so you have access to information. You are lucky that you are in the office with the providers, that makes it so much easier to engage the patients. Good luck with your efforts, it is very rewarding but also very draining! You will need some help for sure!!

I work for large clinic in Midwest and our insurance plan has a call center or "Nurse Line" as we call it here. They have nurses working both in clinic at the center and some from home. Many of the nurses have been there for 15 yrs. I think most of them would never return to staff nursing or even a clinic staff nurse job, they are too far removed from bedside nursing at his point. If you are OK with not seeing your patients or sitting for long hours, this job is great. I don't think it is for everyone, I did Telephone triage for 10 yrs but in an Internal Med department and I also still did procedures and worked with patients face to face. That was the best fit, we got a little of everything without the long hours, lifting and running to catch call lights! You need good assessment skills to do this as the patient is not visible to you so it is key that you have a strong clinical background. I think it is a great job, hope you like it.

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

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.

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! :)

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! :)

Don't most states have reciprocity? I am licensed in WI and I was told I didn't need to get licensed in AZ, CA or TX?

I work in a health plan and we also have noticed increase since the new year. We are hiring "engagement coordinators" to make the initial calls and cull out the members that are going to want to work with a CM. Our patient demographic is largely geriatric with many health issues and in rural area that requires long drives to the clinic and hospital. I agree, nursing is not for faint of heart and even a clinic job can cause you to have sleepless nights.