In 2004, Crystal Run decided to tackle patient health maintenance to ensure its patients were getting routine tests, such as Pap smears, and to ensure the practice was capturing all of its revenue opportunities. The practice hired a care manager to review files and make calls to schedule routine appointments for patients. This undertaking laid the foundation for a care management infrastructure and ultimately a medical home.
“As a bigger group, we were also looking for ways to personalize our care and act on a smaller, more personalized scale. A care manager was a way to smooth the interaction between patient and practice,” Spencer explains.
Though its electronic health record wasn’t in place when it started, the practice decided to morph the direction of the program and pursue a value-based care model with its higher-risk patients. “There’s a tendency in healthcare to believe you can’t identify who the high utilizers are without technology … but realistically the people you think are the high utilizers tend to be. We started with one or two patients to get the process going,” he says.
The organization created a simple template to standardize data collection to aid with messaging among practice members. Then the nurse care manager worked with the physicians to identify patients who needed additional attention—be it tracking weight or taking medications. Eventually the EHR system came online, making identifying patients, as well as communicating among team members, easier.
“The care managers become an extension of the unit: there’s the nurse, the tech and the care manager … They are reaching out, checking in with the patient—it’s more proactive than just a traditional office visit.”
The care manager nurses have grown in number—currently seven—and have increasingly been tasked with high-risk cases, such as high-risk breast cancer follow-up and diabetes, and they are finding success in their outcomes; for instance, in diabetic control in 2009, less than 50% of the practice’s diabetics had A1c’s less than seven (a marker of tight control); two years later the number is nearly 60%.
Crystal Run is now ready to roll out the care manager on a larger scale. Through its involvement in the region’s THINC RHIO, as part of a grant program, it will use the Geisinger model to embed care managers in all its practice’s medical home sites. The project is aimed at helping patients with the care transition from the hospital to their home.
“Right now this approach is just a good idea to help these patients; get some P4P money and increase revenues for basic, covered health maintenance tests. Hopefully it will have more significant business ramifications down the road,” says Spencer. “We aren’t getting paid a tremendous amount for this type of care, but in the future it will be critical to manage these patients.” He adds that Crystal Run believes practice-directed care management is a core competency that will be needed to help manage risk and cost of care in the future.