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When the Carle Clinic Association launched the Partners in Care program for the elderly, the Mahomet, IL, multispecialty practice already had 12 years of case management for the elderly under its belt. The current program evolved over time out of a case management model that was implemented to address the needs of the rapidly growing geriatric population the clinic leaders knew they would be serving in the future.
"We went through a lot of changes in the model. We started with volunteers, then nurse social workers, and finally found that the best solution was a community-based specially trained nurse," explains Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center.
Carle Clinic Association started its case management program for the elderly in 1986 with initial funding from the Kellogg Foundation, Schraeder says. "When we started the concept, it was ahead of its time. There was nothing like it in group practice in the country. Most of the case management at that time was in the social service field with underserved populations, primarily in psychology and public health," Schraeder says.
At the time, nurses were not an integral part of case management programs. This was a concern to the Carle Clinic leadership because they had found that older adult patients, particularly those from the rural areas served by the clinic, often were reluctant to describe accurately how well they were functioning. The clinic doctors and nurses had found that the patients felt freer to discuss their living situations and health problems with nurses than with doctors.
The solution seemed to be an integrated program in which nurses work with the primary care physician, the patient, and the patient’s family to develop and coordinate a health care plan. The practice tried having all of the nurses working in a centralized setting, then moved on to having them decentralized but in their own space. They found that it was most effective for the nurses to be in the community clinic setting where they could be closely aligned with the primary care physicians to enhance the team treatment concept.
That led to the current system in which "nurse partners" are located in clinics throughout the clinic’s treatment area and are responsible for managing the care of patients for specific primary care physicians. "We tried all kinds of communication with physicians, including e-mails and written summaries, but we found that if the physicians and nurses are in the same facility, they can communicate in the hallway or before the start of the day and do quick case reviews instead of scheduling long-term meetings," Schraeder says.
The clinic is one of 15 sites chosen to participate in a Medicare Coordinated Care Demonstration Project. They are taking the same concepts and applying them to chronic conditions such as diabetes, chronic obstructive pulmonary disease, coronary artery disease, stroke, and congestive heart failure.