Nurse Care Coordinators Team Up with PCPs to Improve Care
Standing, from left, Lisa Wichmann, Mary Lou Dolan and Pia Young; seated, Doreen Harvey, Constance MacManus and Ivette Mulero.
BWH nurse care coordinators are playing a central role in an innovative health care cost and quality improvement program.
In February, Brigham and Women’s/Faulkner Hospitals and the Brigham and Women’s Physicians Organization launched the BW/F Care Management Program (CMP) with help from the Department of Care Coordination. This program, which is a demonstration project of the Centers for Medicare and Medicaid Services (CMS), explores an alternative care delivery model for high-risk Medicare patients.
“This is a new way to coordinate care for our sickest and most complex patients with added resources for primary care in a way that will help our patients, families and providers,” said Rebecca Cunningham, MD, medical director for the Care Management Program at BW/F and a primary care physician at Brigham Internal Medical Associates (BIMA).
CMS will identify and invite 1,000 patients from 11 BW/F primary care practices to enroll in this three-year program. BWH nurse care coordinators will work in partnership with the patient’s primary care physician (PCP) to manage proactively the care of each patient.
“We are confident that care coordination efforts in partnership with primary care physicians to address and plan for patient needs before an unexpected medical situation or crisis will greatly improve care and quality of life for these patients,” said Joanne Hogan, MS, RN, executive director of Care Coordination, Ambulatory Nursing and Clinical Services.
In August 2006, the CMS funded the MGH and Massachusetts General Physicians Organization to launch the Care Management Program at MGH, one of just six programs nationwide. Favorable preliminary results, including positive feedback from MGH patients and providers, paved the way to expand the program within Partners HealthCare. In addition to Brigham and Women’s and Faulkner hospitals, the program pilot is expanding to North Shore Medical Center.
The pilot is intended to address the fact that 15 percent of Medicare fee-for-service patients are responsible for approximately 75 percent of total Medicare health care costs. The overarching goal is to improve care for patients while controlling the cost of that care. CMS aims to learn how much primary care practices can reduce overall costs of care of the sickest patients by employing nurse care coordinators.
Five nurse care coordinators will serve as an integral part of the primary care team. Working with the program’s larger multidisciplinary team and an array of community resources, the nurse care coordinator will ensure that the medical and psychosocial needs of the patient are met efficiently and effectively. PCPs and nurse care coordinators will collaborate with other providers and connect patients with enhanced services, including mental health, social work, pharmacy, community-based resources and other services, as appropriate.
In advance of the program launch, BW/F nurse care coordinators trained with their counterparts at MGH, where the program has been in operation for three years. “MGH care managers precepted each of us,” said Connie McManus, MBA, BSN, RN, CPHM, the care coordinator for the Faulkner Community Physicians practice in West Roxbury.
“When one of our patients is admitted, perhaps through the ED, we will assist with that, work with the inpatient care team during their stay and follow up after their discharge to home or to a sub-acute care facility,” McManus said.
The initial outreach to patients has gone smoothly. “Our patients have been very open and receptive to enrolling in this program so far,” said Mary Lou Dolan, BSN, RN.
The potential for such a positive impact on patient care has everyone excited about participating in this new approach.
“In all of my career, this is one of the most exciting programs I’ve been involved with from a care coordination perspective,” said Lisa Wichmann, MS, BSN, RN, nursing program director in Care Coordination who is leading process development efforts for the nurse care coordinators involved in CMP. “We know this program will make a difference in the lives of our patients.”