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Partners in Care, a case management program for the high-risk elderly, has dramatically reduced hospitalization, shortened lengths of stay, and improved care for targeted patients at Carle Clinic Association, PC, in Mahomet, IL. The population served by the program includes 2,000 Medicare patients covered by capitated managed care contracts who are at high risk for mortality, functional decline, and increased use of health care resources. (For information on how patients are chosen for the program, see "Program focuses on elderly with highest risks," in this issue.)
Carle Clinic Association is a multispecialty physician-owned practice with 290 physicians in primary care and medical/surgical specialties. The practice is part of a health care system that includes a hospital, an HMO, and other service companies such as home health, pharmacies, and durable medical equipment suppliers.
Carle Clinic’s Partners in Care program received the Models of Excellence in High-Risk Patient Management award from the American Medical Group Association (AMGA) in Alexandria, VA, and Pfizer, Inc., of New York. Since its inception in 1998, the Partners in Care program has dramatically reduced utilization of health care resources for patients in the program. For instance, patients in Partners in Care were hospitalized for a total of 1,721 bed days per thousand per year, compared with 4,162 bed days per thousand per year among a similar population not in the program. Patients not in the program were hospitalized 858 times per thousand per year, compared to 433 hospitalizations per thousand per year for patients in the program. Partners in Care patients visited their doctors 13.2 times a year, compared with 11.8 visits for those not in the program.
In the Partners in Care program, nurses trained in geriatric care function in an expanded role and are called nurse partners. Primary care physicians provide geriatric care and serve as team leaders. The nurse partner concept combines the duties of an office nurse with a community-based home health provider. Among their duties are:
The nurse partners actively monitor the patients. The nurses visit the patients in multiple venues, such as their homes, the hospital, or nursing home, in addition to the clinic. They give the information they gather during site visits back to the primary care physician.
"This really helps with the ongoing support of the patient population. It helps the patients understand what is happening, what kind of treatment and recommendations their physicians have, and it helps the patients implement the recommended treatments," says Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center. When the patients meet with their doctors, the nurses have an opportunity to sit with them and review what the doctor says to make sure the patients understand it. "We find the same thing is effective after a patient has been hospitalized. They may have heard a lot of things, but they don’t remember it later," Schraeder says.
Outside the office or hospital setting, the nurses help the elderly patients and their families overcome any obstacles to getting the care they need, such as getting proper diet, purchasing medicine, getting enough exercise, or accessing community services. "One issue with an elder who has multiple needs is hooking them to appropriate services such as Meals on Wheels. Partners in Care really helps to provide continuity, monitoring, and support for a person with complex care needs," Schraeder says.
The practice sends nurses into the community cautiously, only when an issue can’t be handled by telephone. "You have to be judicious. They can’t do it all with home visits. It gets too expensive. We are a rural practice and cover a big geographic area," Schraeder says.
The nurse partners are trained to understand the community in which they work as well as the complex medical needs of elderly patients. The nurse partners typically have a history of dealing with a patient population over time as opposed to nurses who see patients who come and go in an acute care setting. "Nurses who are used to seeing people in acute care generally don’t have the kind of skill sets they need to manage patients over the long term," Schraeder says.
"We look for someone with very good clinical skills and independent practice skills. They will be dealing with a panel of complex patients and they need to be able to communicate with the physician, the patient, the family member, and the community," she adds.
Each nurse manages the patients of specific primary care physicians. There are about eight nurse partners, each of whom supports the patients from five to six primary care physicians, spread out in clinics throughout the Carle Clinic Association treatment area. They are coordinated by a nurse manager and a program developer.
The nurse partners are assisted by care assistants, most of whom have worked in community agencies. They answer the telephone, take care of some administrative tasks, arrange for services (such as a homemaker service), and do some telephone monitoring, checking in with the patients and alerting the nurse partner if the patient needs to make an appointment. "The care assistants tend to be mature with some experience. Because they are talking with the elder population, they need to feel comfortable with that group. It’s not just administrative work; it’s communicating with patients and negotiating with service providers," Schraeder says.
[Editor’s note: For a copy of a Compendium of the AMGA-Pfizer Models of Excellent awards, contact Clese Erikson, director of research, American Medical Group Association, 1442 Duke St., Alexandria, VA 22314-2340. Telephone: (703) 838-0033, ext. 347. E-mail: email@example.com.]