The Coming Age of the Patient Navigator

Cheryl Clark, for HealthLeaders Media , April 26, 2011
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Editor's note: This story was originally published in the April issue of HealthLeaders Magazine

They’re called embedded care managers, patient navigators, even geriatric coordinators. In fact, they’re called dozens of other names as well.

Increasingly, health plans and physicians’ offices are catching on to the idea that this extra layer of personnel support—whatever they’re called—might help physicians and hospitals manage difficult or recalcitrant patients whose multiple health issues keep drawing them back into the hospital.

These case managers tend to be registered nurses who sometimes work from a remote location by phone. Or with increasing frequency, they may work directly with the physician in the office practice. Sometimes they visit patients’ homes. The goal is the same: to make sure that gaps in care are shut.

Cigna, for example, a health plan with 11 million lives, started requiring embedded care coordinators in 2008 when it signed a contract with the Dartmouth-Hitchcock physicians group in New Hampshire. Today it has eight such contracts. And they’re being added “aggressively,” says Cigna spokesman Mark Slitt, with a total of 30 physician practice contracts including
that language covering nearly 500,000 lives currently.

Jennifer Farlow, RN, BSN, is one such coordinator. She began in June 2010 with Atlanta area’s Piedmont Physicians Group, which has since added two health coaches and a clinical case manager to help out. Each month she receives a list of patients with the highest medical costs, including their frequency of emergency department use, and a gaps-in-care report listing people with chronic conditions, such as diabetes, who need monitoring.

She checks the files for patients who haven’t been in to see their primary care physician in a while. She gets on the phone and calls each one.

“I try to identify their barriers to care. And it turns out there’s a lot of reasons, a lot of them financial—they know they can get in to see a doctor in the ER for free, but a visit to the doctor requires a $30 to $40 copay.” Other patients say they tried to make an appointment, but the doctor required too long of a wait. Farlow helps them make appropriate financial or other arrangements so that they get an appointment as soon as possible.

With increasing financial penalties for hospitals and doctors whose patients are frequently readmitted and cost the system too much money, there’s been a change of thinking about the cost-effectiveness of the disease manager, says Robert Wachter, MD, professor and chief of the division of hospital medicine at the University of California, San Francisco.

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1 comments on "The Coming Age of the Patient Navigator"

stefani (5/20/2011 at 11:56 AM)
For years, hospitals have attempted to extend hospital case mgt beyond the borders of the facility. Uncompensated Expenses usually spell the end of these progressive projects. Insurance companies with their large profits and their shareholders who demand ROI, can afford these new FTEs. But as we all know, with every hand-off, something falls through the gap. Extending hospital case mgmt - and paying for it -is an idea whose time has come. Unfortunately, Under the Partnership for Patients, CMS will fund transition projects but hosptials will not be eligible unless they enter into a venture with a CBO. That's not a step in the right direction.




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