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Role of Nurses in Health Plans, Part II
The document discusses a meeting between health plans and the Center to Champion Nursing in America to support the IOM's recommendations. It describes how health plans are driving innovations through nurse-led programs that improve quality of care, consumer experience, and health outcomes. Examples are provided of single nurse care manager models and personalized care plans that have led to measurable improvements such as reduced healthcare costs, fewer emergency visits, and better diabetes management.
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Role of Nurses in Health Plans, Part II
- 1.
- 2. Susan Reinhard, PhD,RN, FAAN Senior Vice President & Director, AARP Public Policy Institute; Chief Strategist, Center to Champion Nursing in America www.championnursing.org/events 2
- 3. Advancing Education Removing Barriers to Nursing Leadership Transformation Practice and Care Interprofessional Collaboration Diversity DATA
- 4. • Highlight thelinks between nurses, health plans, the future of health care delivery, and the IOM’s recommendations. • Describe the variety of ways that health plans are driving innovations. • Demonstrate the value and impact nurses have on the quality and outcomes of healthcare delivery by sharing examples of specific programs from various health plans. • Highlight the impact that nurses have on the overall consumer experience. 4
- 5. Susan Kosman, RN,BSN, MS Chief Nursing Officer Aetna Inc. 5
- 6. The Health PlansWork Team works to support the IOM recommendations by: • Discussing implications regarding health plans • Sharing the IOM’s report within respective organizations • Brainstorming actions that health plans can take • Collaborating where possible on actions • Educating constituents on the various roles that nurses play in health plans, the linkage to the IOM’s recommendations and the future of health care delivery 6
- 7. • Susan Kosman,RN, BSN, MS, Aetna, Inc. • Shelley Balfour, RN, BSN, MBA, Aetna, Inc. • Diane Hogan, DNP, RN, MA, Humana Cares • Susan M. Pisano, America's Health Insurance Plans (AHIP) • Cynthia G. Wark, America's Health Insurance Plans (AHIP) • Mary Aikins, RN, BA, CCM, Horizon Healthcare Innovations - Patient Centered Medical Home • Tom Michels, RN, HealthPartners Medical Group • Jared T. Skok, MPA, Blue Cross and Blue Shield of Florida Foundation 7
- 8. The model isdesigned Sees the whole person and passionately supports to reduce health risk them through their mind, body, and cultural values Holistic and boost member Approach Comprehensive view of member data output: Integrated about each individual to determine an Medical appropriate level of support More Sources Engagement Effectively identifies and Clinical engages members earlier Continued Algorithm while capturing preferences relationship around programs and services across care continuum Designates a true single- Single Nurse point of contact offering Member-centric Model a 360 degree view of each approach addressing member’s needs Cultural needs Multi-Modal Engages members through our virtual Support support channels who have less urgent care needs and to supplement the one-on-one support 8
- 9. A single NURSEpoint of contact serves as the PRIMARY CARE MANAGER for members’ health care needs and their families’ needs Benefits of Single Nurse Sample Outcomes Nurses are able to customize Assist members/families with a personalized health strategy preparing for a hospital stay or around the individual planning for recovery Fewer hand-offs permitting Educate members and families faster, simpler responses from on how to make the best use of someone members know and their benefits plan trust Provide tips to stay healthy More relevant responses to Find resources through benefit members’ needs plan or in local community 9
- 10. Members receive individualizedcare plans based on their health needs and what they need to be successful Care plans are individualized based on member preferences A variety of modalities are available to meet member needs – online, phone, e-mail, group/social networks, text, or chat Member engagement tools put information at members’ fingertips so they can stay on top of their health needs 10
- 11. Member Health Background–Gina* A 60 year old female admitted to the emergency toom with shortness of breath, weakness and nausea Diagnosed with Atrial Flutter with A-V block Co-morbid conditions included obesity, hypertension, hypothyroidism, hyperlipidemia, a torn medial meniscus of the left knee, and a new diabetes diagnosis 11
- 12. Clinical Support -How we helped Primary Care Nurse helping to manage care across care continuum Collaboration and communications with care providers Educational support to manage conditions Goal setting for weight loss and diabetes control Care coordination of resources across care needs Identification and removal of barriers to achieving goals and changing behaviors 12
- 13. Health Outcomes -Measurable Change Reduction in HbA1C Weight loss Behavior change Continued participation in diabetes classes Improved knowledge and understanding of managing chronic conditions and associated risks 13
- 14. Long-term Success -A Better Outcome Diabetes under control Weight loss Established partnership and relationship with Primary Care Nurse Manager Better informed and aware of managing conditions Actively engaged in prevention and maintenance of conditions Increased confidence in achieving goals 14
- 15. Mary Aikins, RN,BA, CCM Manager, Care Management Operations Horizon Healthcare Innovations - Patient Centered Medical Home 15
- 16. • Horizon HealthcareInnovations - Through collaboration, we are helping to create an effective, efficient and affordable health care system 1 2 • Achieving better health, better care at lower costs Triple Aim Enhance the Patient Experience 3 16
- 17. Today’s Care Model Patient-Centered Medical Home Self Care ER Doctor Pulmonologist ? Care Mgmt Patient & & Care APN Education Team Patient Physical Pharmacy Cardiologist Therapist Engaging & empowering patients is critical to providing better care at lower costs 17
- 18. • A Patient-CenteredMedical Home… – Coordinates the right care, at the right place, at the right time – Customizes & personalizes care plans, wellness and preventive care – Immediate access for chronic and at-risk patients • Focus is on chronic and at-risk patients but available to all Horizon members – Chronic conditions, behavioral health, transitions in care • Scope of PCMH Initiative: – 22 practices covering 80,000 Horizon BCBSNJ members – Expand significantly throughout 2012 18
- 19. Quality Measures • 8%higher rate in improved diabetes control (HbA1c) • 6% higher rate in breast cancer screening • 6% higher rate in cervical cancer screening Cost and Utilization Indicators • 10% lower cost of care (per member per month) • 26% lower rate in emergency room visits • 25% lower rate in hospital readmissions • 21% lower rate in hospital inpatient admissions • 5% higher rate in the use of generic prescriptions 19
- 20. Population Care Coordinators Engage, Playbook & Educate & Learning Empower Network Patients Better Health, Better Care, Lower Costs Data & Payment Technology Reform 20
- 21. Population Care Population Care Coordinator Education Coordinators Program • Nurses who work within PCMH • Created a nurse education practices program with Rutgers and Duke • Help improve the coordination nursing schools of care for patients • Partnership will educate a • Follow up with patients to minimum of 200 nurses over address any of their needs the next two years • Continuously update • Building a transformed nursing personalized health plans role to support new care models • Proactively engage, educate and • Nurses will be deployed to empower patients PCMH and ACO programs throughout NJ 21
- 22. A full timepopulation care coordinator (PCC) is expected to carry a full-time case load of approximately 150 high risk patients or approximately 2,500 to 3,000 patients • PCC must be an RN with a valid nursing license in the State of NJ • Must have at least 3 to 5 years of clinical experience and ideally have experience in discharge planning, case or disease management • The PCC must be hired, educated through the new program and integrated within 6 months of joining the program • The PCC leads key care coordination activities conducted by the practice • Horizon funds the PCC Education Program 22
- 23. Patient visits provider; clinical data collected New data enables Sharing Provider shares providers to focus on Data to relevant clinical data opportunity to improve Understand with HHI care, reduce costs Patient Population & Take Action Review findings with Analyze data from care teams during provider and other collaborative work sources of possible sessions patient utilization 23
- 25. • Collaboration: Nurses,physicians, hospitals, health plans, employers and other stakeholders must work together to transform the delivery system • Population Care Coordinators: These nurse leaders are key to driving improvement to deliver better care at a lower cost • Patients in PCMH/ACO Programs: Approximately 200,000 Horizon BCBSNJ members will be participating by Dec. 2012 • Program goals: » Better Health Outcomes » Better Patient Experience » Lower Cost of Care 25
- 26. Diane Hogan DNP,RN, MA Director of Clinical Innovations Humana Cares 26
- 27. Linking medical andbehavioral care with social care to combat the challenges of aging and chronic illness Creates • “Scorable Savings” year after year • Measurable improvements in health • Satisfaction for member and providers • Measurable improvements in quality of life • Transforms healthcare delivery 27
- 28. • Acute Chronicity: A dynamic chain of good health days and bad health days. Interventions need to be flexible and responsive along the continuum of care • Humana Cares Managers respond to member needs and adjust levels of intervention to meet changing concerns. This, along with clinical judgment, drives the next steps and care pathways. 28
- 29. Fragmentation of Carea Serious Problem in the Medicare Population Members are seeing, on average about 13 providers per year… They take on average 8-10 medications… 29
- 30. 82% of seniorshave a chronic condition – 62% have two or more Medicare member profiles 21.5 $7,478 million per 16.5 $3,455 seniors person million per seniors person 4.2 $14,680 million per seniors person 39.1% 51.0% 9.9% In excellent health In good health In poor health Costs double at each change in health status Source: MedPAC analysis of the Medicare Current Beneficiary Survey, Cost and Use file, 2003, as reported in the June 2006 Data Book: Healthcare spending and the Medicare program. Medicare Advantage average reimbursement per MA enrollee/year was $7,218 in 2004. 30
- 31. Compared to OtherPeople Your Age, How Would You Describe Your Health? 100% PMPY Total Costs $18,000 $16,453 $16,000 80% $14,000 Cost Drivers Percent Response $10,280 $12,000 60% $10,000 52% 48% $8,000 40% $6,000 20% $4,000 $2,000 0% $0 Excellent or Good Fair or Poor 31
- 32. Humana Cares Provides“life care” advocate in navigating confusing provider systems Supports client to remain independent and safe, for as long as possible, in their home Creates “one stop care” for medical and quality of life needs Encourages and supports the client, family and care givers to take an active part in their own healthcare Connects client to community resources and services Anticipatory guidance assists client in identifying and dealing with small problems before they escalate in to major physical and financial problems. “People do not care how much you know until they know how much you care” 32
- 33.
- 34. • Majority ofparticipants indicated they benefited from the program and the interaction with their Humana Cares Nurse. • Evaluations measuring traits of Humana Cares Nurses were outstanding. They said their nurses were knowledgeable and cared for them in an individualized, courteous, and supportive manner. • The program experience and working with the nurse produced anticipated positive outcomes in the future for most, evidenced by decreased utilization, improvement in health screening and clinical outcomes. • Two-thirds said they would make a change in how they take care of their health in the future as a result of working with the Humana Cares Nurse. • Nine out of ten said they would continue to work with their Humana Cares Nurse. A positive outcome, supporting the retention objective. 34
- 35. Community Health Educator Humana Cares Telephonic & Field Manager Telephonic Humana Cares Manager Humana Cares – Social Services Manager – Behavioral Telephonic Health Telephonic Field Care Manager Field 35
- 36. • Mr. Simone,73 year old male, diagnosed with Type 2 diabetes, hypertension, with history of heart attack, early dementia, depression, and prostate cancer, is married and lives with his spouse in a rented apartment • Member enrolled in the HC Complex Care Management program since October 2010 Areas of Concern • Focus on chronic condition management (i.e. diabetes eye exam, depression) • Difficulty sleeping due to anxiety r/t landlord threat of eviction; assessment uncovered issue of frequent urination • Newly diagnosed prostate cancer • Fall history • Pain Management • Eviction and housing needs • Financial issues related to life transitions 36
- 37. Health Preventive measures and health risk reduction Education and support for diabetes management and tobacco Support cessation; sleep problems, fall risk reduction Care Post discharge support; Partnering with PCP and Coordination oncologist; Pain management Member-driven action plans, care plans and care Chronic manager-guided coaching, and clinical Condition interventions (i.e. cancer treatment, depression Management and dementia) Care navigator; caregiver support and Advocacy and connections to pharmacy assistance and Care Navigation community resources (i.e.HUD, Michigan Choice chore services) 37
- 38. Complex and chroniccare management enhances the care continuum and extends reach beyond case management and disease management It’ s more than the case or the disease …. It is all about the Member, the Family/Caregiver, and Quality of Life 38
- 39.
- 40. • Upcoming Webinarson Leadership: – September 24, 2012 - Sigma Theta Tau International Leadership Institute • Archived webinars www.championnursing.org/events • Request Toolkit : Nurse Leaders in the Boardroom: The Skills You Need to be Successful on a Board http://championnursing.org/nurse-leaders-resource 40
- 41. Visit us onthe Web http://thefutureofnursing.org http://championnursing.org Follow us on twitter www.twitter.com/futureofnursing http://twitter.com/championnursing Join us on Facebook http://facebook.com/futureofnursing http://www.facebook.com/championnursing 41
Editor's Notes
- #3 Susan ReinhardThank you for joining us for today’s webinar on Transforming Healthcare Delivery: The Role of Nurses in Health Plans – Part II of a two-part series. As many of you probably know, we hosted the first part of this series two weeks ago on May 29th. Susan Kosman, Chief Nursing Officer for Aetna Inc. and Diane Hogan, Director of Clinical Innovations at Humana Cares gave a great overview of theunique role that health plans play in the health care system and on the various roles that nurses fill which enable them to lead change to advance health among consumers. If you missed it, you can find the recording by going to www.championnursing.org/events.Before we go much further, I wanted to mention that we are recording today’s webinar, so if you miss a section or would like to pass it on to a colleague, you can find the recording by going to the same web address. We will also leave some time for questions from those on the phone after the presentation. So if you have a question, you can either type it in on the chat area on your screen or write it down and hold on to it. You’ll have an opportunity to ask it after the presentation.
- #4 Susan Reinhard:Since some on the call may not be familiar with the Future of Nursing: Campaign for Action, I will provide some quick background. The Campaign for Action is coordinated through the Center to Champion Nursing in America (CCNA) and includes 49 state Action Coalitions anda wide range of health care providers, consumer advocates, policy-makers, and the business, academic and philanthropic communities. The Campaign's Vision is for all Americans to have access to high-quality, patient-centered care in a health care system where nurses contribute as essential partners in achieving success.The campaign is focused on five key areas. They are: -Strengthening nurse education and training;-Enabling nurses to practice to the full level of their education and training;-Expanding leadership ranks to ensure that nurses have a voice on management teams, in boardrooms and during policy debates;-Advancing interprofessional collaboration across the health spectrum; and-Diversity, which is a thread that weaves through each of the other four areas.We have given special attention to this with the creation of the Future of Nursing Diversity Steering Committee.Improving health care workforce data collection is the foundation underlying each of the pillar areas.We are happy to focus today’s webinar on the Role of Nurses in Health Plans because it aligns with thecampaign’s vision and the key area of nursing leadership. Health plans also play a big role among our State Action Coalitions; many have partnered withhealth plans to help advance their work and four of our Action Coalitions have co-leads who represent health plans.
- #5 Susan ReinhardNurses fill a variety of roles in health plans, contributing to the campaign’s vision of quality, patient and family-centered care. In part one of this webinar series, nurse leaders spoke about the mission of health plans and the unique role they play in the overall health care system. Our goal for today’s webinar is to provide an opportunity to hear from more nurse leaders in health plans who will:1. Highlight the links between nurses, health plans, the future of health care delivery, and the IOM’s Future of Nursing report recommendations.2. Describe the variety of ways that health plans are driving innovations through programs and services that address access, quality and cost of care.3.Demonstrate the value and impact nurses have on the quality and outcomes of healthcare delivery by sharing examples of specific programs from various health plans.4. Highlight the impact that nurses have on the overall consumer experience through their roles in health plans.
- #6 Susan Reinhard:Now, I’d like to introduce our first speaker Susan Kosman who will provide an example of a nurse-coordinated program in health plans that have shown better health outcomes for consumers.Susanis the Chief Nursing Officer for Aetna where she is responsible for leading Aetna’s nursing strategy, this includes leadership, development, and workforce planning for Aetna’s 3,000 nurses. She also leads Innovation and Program Design for Aetna’s suite of Care Management Programs, Clinical Learning & Performance and the Systems & Reporting team. Susan is a Board member of the Aetna Foundation, Qualidigm (a healthcare consulting and research firm), and the American Heart Association, Greater Hartford chapter. Susan represents Aetna on the American Organization of Nurse Executives Committee on Health Care Reform and the Center to Champion Nursing in America’s Champion Nursing Coalition. I would also like to recognize her hard work and leadership in developing the Health Plans Work Team in support of Campaign for Action, which she will share more about shortly.Susan…
- #7 Susan KosmanThank you Susan. We mentioned on part-one of the webinar series but, I just wanted to mention that as Susan introduced, in response to the IOM’s Future of Nursing report, a diverse group of nurse leaders across various health plans and members from America’s Health Insurance Plans have been meeting for the past year to focus on:Discussing the Future of Nursing report and the implications on health plans.Sharing the IOM’s report within our respective organization.Brainstorming ideas/actions that health plans can take to support/advance the IOM’s recommendations.Collaborating where possible on actions that support the IOM’s recommendations.Develop this webinar that describes the various roles that nurses play in health plans, the linkage to the IOM’s. recommendations, and the future of health care.
- #8 Susan KosmanI would like to, again, give a special thanks to all those who are a part of the Health Plans Work team and have worked extremely hard on putting together the content for today’s webinar.
- #9 Susan KosmanAetna has a variety of programs that focus on engaging members across the care and life continuum while also addressing access , quality and cost.In Touch Care is one of Aetna’s newest models of care delivery. There were a number of factors that led us to create this approach, including feedback from from our plan sponsor (employer)groups, member feedback about multiple touch points across various programs that they may be part of, Aetna nurses providing feedback and suggestions on how they could better engage and work with members in driving better outcomes, and of course, reviewing data and market trends on more effective care delivery models. In considering all the data and feedback, we decided to develop a model that would address the se needs by; Improving identification and stratification of members who in priority fashion could benefit from services at the right time, the right level and the right setting Care coordination across care continuum and also, Improving the members’ whole experience We assemble d a multi-disciplinary team of nurses, physicians, informatics, program design, quality, finance , sales and marketing to design, develop, implement and market the new model. The collaboration across the teams was instrumental in the success of how we designed, delivered and ultimately measured the effectiveness of the modelFor the purposes of today’s webinar, I will focus and expound on a critical component of this program which is the role of the nurse as a single point of contact. I will also highlight the member experience and outcomes as it relates to this model
- #10 Susan KosmanEmployers health plans often include a variety of programs available to members. For example case management and disease management. These programs provide great opportunities for members to have access to a variety of tools and services to assist them in addressing their health and wellness needs. In some instances, this translate into multiple conversations for members with multiple clinicians across the different programs. By rethinking the way members are identified and assigned, creates a different experience for members while preserving the benefits of the program components.We wanted to change the members’ experience and interactions by creating a new and innovative approach to managing members through better prediction, personalization, and participation. This meant having one nurse be the primary and single point of contact for a member during each stage of the health and life continuum, the ability to respond with the appropriate level and method of intervention based on an individual’s need and preference. We believe this would help to better drive and facilitate member engagement and to build a long-term relationships between member, nurse, and provider.To accomplish developing the new innovative approach, the multi-disciplinary project team had to evaluate current programs, develop new capabilities to support a new delivery model and to prepare staff to deliver in this new model. Our nurses played a critical role at every stage along the way and they continue to be the life-line for further refinements and enhancements.
- #11 Susan KosmanThis model manages members with both acute and chronic care issues through a single nurse- referred to as the Primary Care Manager. They use a holistic approach which includes a member’s clinical and cultural needs. The Primary Care Manager considers both internal and external influences on an individuals health status to customize a care plan around the individual and their cultural values. The Primary Care manager is not only the member’snurse, but can assist all dependents to become a family resource. Nurses provide a personalized care plan around the individual’s needs and may provide support and navigation to all members of the family. Through this approach, we are able to help the member and their families get an appropriate level of support and meet their clinical needs. There are a variety of behind the scenes data support elements and triggers that present our nurses with the ability to make contact with members at a point in their care and treatment when it really matters. For example, the program will identify members with a higher likelihood of a hospitalization in the next nine months to attempt to avoid an admission. At its core, the model takes a member –centric approach which enable the nurse to use a holistic approach to engage members with optimal program resources and intensity, and provides additional means for support, based on member preference and need.. Next, I would like to share a member experience with you that will bring to life some of the aspects of the program that I described.
- #12 Susan KosmanMember Health BackgroundMeet Gina* (not her real name), A 60 year old female admitted to the ER with shortness of breath, weakness and nausea. She was diagnosed with Atrial Flutter with A-V block. She was given a new diagnosis of diabetes. She was discharged home after medication cardioversion. Co-morbid conditions included obesity, hypertension, hypothyroidism, hyperlipidemia, a torn medial meniscus of the left knee, and the new diabetes diagnosis. Medications at discharge included her pre admission medications for blood pressure, thyroid, and cholesterol medications as well as new insulin medications.
- #13 Susan KosmanThe Aetna In Touch Care (AITC) Care Manager outreached to the member who agreed to participate in the Aetna In Touch Care Program. Issues identified between the care manager and the member included a knowledge deficit of a number of new medications, the new diagnosis of diabetes and insulin management, and a torn meniscus requiring surgery. The surgeon indicated that he would not perform the surgery until her HbA1c was under 8.0. Her initial HbA1c was 13.4. The prioritized goals based on Members care plan: 1. HbA1c less than 8.0 to allow left knee surgery.2. Diabetes control with diet, exercise and oral medications to allow discontinuation of insulin. 3. Weight loss for diabetes control.4. Increased activity, endurance and strength using outpatient therapy and pool walking.5. Return to work post knee surgery with ability to ambulate without device. At times the member was tearful but denied depression. She indicated that she had a long history of poor diet and minimal exercise. The care manager provided emotional support and encouragement to follow through with her diet and exercise. The member expressed comfort with talking with care manager and agreed to continued bi-weekly contact. The care manager contacted the primary care/diabetes provider. The primary care provider identified the plan of care for the member for which the care manager supported in conversations with the member.The same Care Management Nurse provided continual support beginning with her acute situation in the hospital through the management and control of her newly diagnosed chronic condition until she was ready to transition to virtual care support.Some of the Nurse Care Manager interventions included:Providing educational support on her new medications, managing her diabetes, her torn meniscus, and preparing for surgeryEstablishing goals to achieve short and long term care needsIdentifying and assisting with overcoming barriers to increasing her activity for weight loss and controlling diabetesReaching out to other care providers to coordinate care
- #14 Susan KosmanHealth OutcomesWithin a 4 week period the member progressed toward her goals with a change in HbA1c 13.4. to 10.6 by implementing her nutrition and activity plan. At that time the member purchased an exercise glider and began using it daily. She had a 20 pound weight loss and was still attending diabetes classes. She eliminated fruit juices and sweets from diet, and was eating whole grains. As she progressed toward her goals she experienced a more positive attitude and pleased with her progress.
- #15 Susan KosmanLong-Term SuccessBy working with the Primary Care Nurse, this member was able to reach her goals and was in a better position to plan for her knee surgery. She verbalized a good understanding of managing her diabetes, felt more positive and confident after having achieved her goals. She was transitioned to Aetna In Touch Care Virtual Support programs which provided her with continued support for diabetes management and coordination and planning for other needed resources.
- #16 Susan ReinhardThank you Susan. Mary Aikins will present our next example of nurse-led programs in health plans.Mary is Manager of Care Management Operations for Horizon Healthcare Innovations (HHI). In this role she is developing the models with the Patient-Centered Medical Home team. Additionally she recruits, hires and trains and manages the Nurse Population Care Coordinators who practice in the HHI PCMHs. Prior to joining HHI, Mary owned and managed Medical Management Techniques, Inc, a medical case management and consulting firm for 17 years. Her firm specialized in complex case management, disease management, early intervention telephonic case management and customized PPO network development for insurance companies, self funded groups, school districts, municipalities and Third Party Administrators. She has held several organization positions such as President of the NJ Chapter of the International Association of Rehabilitation Professionals, Secretary of the National Board of Directors of the International Association of Rehabilitation Professionals and Treasurer of the Board of Directors of CMSA- Northern NJ chapter. Mary…
- #17 Mary AikinsThank you Susan.Let me begin by acknowledging the Center to Champion Nursing in America (CCNA) and AARP for their leadership and advocacy on supporting Future of Nursing: Campaign for Action as we enter this transformative era in health care. Today, I am here to discuss the landmark results around Horizon BCBSNJ’s Patient-Centered Medical Home Program and the role that Nurses have played in achieving those results. I also want to touch on Horizon’s approach to deliver robust transformation and what we have concluded are the core elements to achieve sustainable results. I first want to discuss Horizon’s approach to developing a subsidiary company, Horizon Healthcare Innovation, to drive a positive health care transformation in the marketplace.Horizon Healthcare Innovations was developed to solely address two fundamental problems: lagging quality of care and cost containment. The only way to truly address these issues is to fundamentally change how health care is delivered and that is the goal of Horizon Healthcare Innovations – to lead a collaborative effort with health care professionals across New Jersey to find ways to deliver better health and better health care at a lower cost. We think of Horizon Healthcare Innovations as a research and development organization to improve the delivery of health care in New Jersey. Our effort is focused on three core priorities, the Triple Aim:To improve the quality and coordination of care to create a healthier populationTo deliver a better overall member experience, andTo reduce the total cost of health care to make health insurance more affordable for our members.
- #18 Mary AikinsMuch of our efforts have focused on developing a collaborative Patient-Centered Medical Home program. So, what is the medical home? A Patient-Centered Medical Home is a primary care delivery model that puts the patient at the center of the delivery system.It helps ensure patients receive accessible, proactive and coordinated care at right place and at the right time.
- #19 Mary AikinsOur medical home model was developed and designed in strong collaboration with eight New Jersey primary care physicians and leadership of the New Jersey Academy of Family Physicians. And, I want to highlight the fact that this model could not have been achieved in a silo. The program would not have been as successful if we dictated a model to physicians. By working together, and by continuing to collaborate to revise, refine and adapt the model, we have and will continue to make great strides on behalf of our patients and members.The focus is on the chronic and at-risk patients, but available to all Horizon Members.New Jersey’s Patient-Centered Medical Home Program currently includes over 80,000 members supported by over 150 physicians at 22 practices. By the end of this year, approximately 200,000 members will be participating in our medical home
- #20 Mary AikinsNow to our results. We compared 2011 preliminary quality and cost trends between 24,000 Horizon BCBSNJ members participating in the PCMH program and a control group not in the program.As you can see, findings show that patients within the PCMH program are benefiting and the costs are lower.Read a few of the results.
- #21 Mary AikinsBesides robust collaboration, we have identified five core elements necessary for a medical home to achieve sustainable results. The core elements include: Payment reform – moving away from fee-for-service to fee-for-valueThe effective use of population care coordinatorsA PCMH playbook and collaborative learning networkThe sharing of actionable data through technology, andThe ability to help practices engage, educate and empower patients.I want to go into deeper detail on payment reform and population care coordinators.Payment reform is critical to transforming the delivery system. We need to move away from fee-for-service and toward reimbursing physicians for getting and keeping their patients healthy. Health care professionals should be paid based on the quality of care they deliver to our members, not on the volume of procedures, visits or tests.How we pay for health care as an insurance company must provide the right incentives for what our members ultimately want from their physicians and hospitals: care that meets the highest standards at the most affordable cost. Our financial model includes the following: continued payment for fee for service, a care coordination payment which includes a subsidy for a nurse care coordinator, and the ability to achieve outcomes-based payment based on delivering better quality, a better patient experience and lowering utilization like unnecessary ER visits and readmissions. It is critical to support practices with additional resources as well. Let me be clear on this point, throwing more money at a broken system will NOT help health insurers, providers and, most importantly, our patients. We believe that developing and supporting resources with our partners will achieve better results in a timely fashion.
- #22 Mary AikinsAnother core component to achieve success is using Population Care Coordinators, who are nurses located within the practices. Care coordinators are strong communicators that proactively engage individuals with chronic and at-risk health conditions, and those with behavioral health concerns. These nurses play a pivotal leadership role by working with the primary care physicians and their teams, and helping coordinate care.We also felt that it was necessary to develop an academic program to ensure the care coordinators are educated on all aspects of the medical home program.Horizon collaborated with the Duke University School of Nursing and the Rutgers College of Nursing to create the Population Care Coordinator Education Program. Together, we designed a curriculum and an education program for these new nursing leaders. Over the next two years, this program will educate at least 200 nurses, who will then be deployed to medical home or other primary-care based efforts, like accountable care organizations.
- #23 Mary AikinsA Population Care Coordinator is an RN with a valid nursing license in NJ, must have 3-5 years of clinical experience and ideally have experience in discharge planning, case and or disease management. As indicated on the previous slide, we will have these nurses participate in the HHI/Duke/Rutgers PCC training program.The 12-week course focuses on the enhanced training of the nurses in:Effective communication strategies with patients and health care providersAccessing and using databases including disease registries and Electronic Medical RecordsCase management of complex patients Patient coaching and coordinating transitions of care Implementing and managing change in health care organizationsOperations of a Patient Centered Medical Home Role of population care coordinators in improving patient outcomes
- #24 Mary AikinsWe are also arming our Nurses and partner physician PCMH practices with Data and Technology to enhance their ability to perform meaningful Population Management. As we move, in our model, from Care Management and planning in support of patients being housed more centrally in a health plan to the patient centered focus of a Patient Centered Medical Home, these physicians, with the assistance of our nurses, need to be able to identify and take actionable steps to address the conditions of those chronically ill patients before their conditions deteriorate. They also need to be enabled to support the preventative health screenings and teaching for all patients.
- #25 Mary AikinsAlso in support of these efforts, HHI designed and built, with the input of our nurses a Care Planning platform to meet the needs of the patient centered medical home model. It allows for data exchange with the practices and the health planIt supports individual care planning for patients in the practice andIt allows population management through varying sorting and queering capabilities.But let me re-affirm that all of this work, in the design of new models of care, creating partnerships with physicians and health plans, designing new nursing curriculum content as a partnership with Duke and Rutgers Schools of Nursing and building of technology to support the effort is all done with patient satisfaction and population wellness, as well as cost reduction as goals.One touching example from one of my Population Care Coordinators:Claudia the population care coordinator identified a patient in the system as being high risk list. She was a diagnosed diabetic whose last labs indicated an H1AC 11.5 from 11-10-10. she had not had a mammo although she turned 40 this year, no pap since 2009, and had no eye exam. Claudia outreached to the patient to schedule a planned visit and begin the patient education on the importance of maintaining the structures to ensure her wellness. While in discussion, the patient shared that she had recently been having some shortness of breath and chest pain. The patient was scheduled for an appointment in the patient centered medical home later that day. Upon exam it was determined that the patient needed to have a cardiac cath and placement of stents. Three weeks after the procedure, the patient came back to the primary care doctor and asked to see both the doctor and Claudia. The patient said she wanted both to know that they had saved her life, but it was because the had been reaching out in support of prevention and wellness. Claudia describes it as an enormously fulfilling moment as a nurse as she was truly able to the impact of nursing across the continuum of care.
- #26 Mary AikinsSo really, in summary, our Horizon Healthcare Innovations Patent Centered Medical Home model is about the collaboration with nurses, physicians, health plans and employers and other stakeholders who must work together to transform the delivery system.And our nurses are a pivotal component to delivering that better care at lower costs and with better patient experience.
- #27 Susan ReinhardThank you Mary. And now we will hear from Diane Hogan. Dianeis the Director of Clinical Innovations for Humana Cares, a subsidiary of Humana Inc., which provides complex and chronic condition management to over 200,000 members nationwide. Her role encompasses clinical program development, clinical process strategy, quality, compliance, performance improvement, policy, and staff education oversight. Diane has held leadership positions in the health business sector and has extensive clinical and nursing education experience. She is an active participant in internal studies, pilots and collaborative research projects and professional presentations and actively participates in Humana’s clinical strategy, quality, compliance and best practice committees.Diane…
- #28 DianeHumana Cares provides integrated health care solutions serving as Humana’s care management provider for complex care, dual and chronic care special needs plans and chronic and specialty condition management. Humana acquired Green Ribbon Health in August 2008 to initiate specialized care management programs for chronically ill Medicare Advantage members. These programs are integrated into Humana’s health service offerings, and are branded as Humana Cares. Humana Cares works with over 200,000 Medicare Advantage, Medicaid and commercial members telephonically in all 50 states, and is on the ground with field staff infrastructure in 34 states. These programs are designed to link health care and social care, allowing members to remain as healthy and independent as possible in their homes.Provides “life care” advocate in navigating confusing provider systemsSupports client to remain independent and safe, for as long as possible, in their homeAssists in decreasing burden on family by providing a personal expert care manager to help the client develop and navigate their plan of careCreates “one stop care” for medical and quality of life needsProvides a multi-disciplinary team of resources-Medical Director, Nurses, Social Workers, Registered Dieticians, Diabetes Educators, PharmacistsAssists client in preserving autonomy by providing choices and informationEncourages and supports the client, family and care givers to take an active part in their own healthcareConnects client to community resources and servicesAssists client in identifying and dealing with small problems before they escalate in to major physical and financial problems.“People do not care how much you know until they know how much you care”
- #29 DianeComplex care members are those living and coping with one or more chronic, life long conditions, with good days and bad days, acute and chronic needsFrail, disabled, vulnerable ,Need high degree of self-care management support,Highfuture riskThose with the most impactableneeds, Facing end-of-life concerns, may be dually eligible for Medicare and MedicaidWe practice a “member for life” philosophy. Studies have demonstrated a strong “dosage effect “ whereby member cost and utilization decreases and stabilizes the longer members are in care management. Humana Cares’ mission is to provide a highly trained, multidisciplinary care management team - telephonically and in the field - to address the complex, acute and chronic care needs of chronically ill Humana members. Humana Cares links medical and behavioral care with social care to combat the challenges of aging and chronic illness. Humana Cares Managers respond to member needs and adjust levels of intervention to meet changing concerns. All of this plus clinical judgment drives the next steps and care pathways. Program goals are to optimize health and well-being “member-by-member” by:Assessing the member’s total health status over timeSupporting informed healthcare consumerism and member’s ability to self-manageProviding individualized health education to help member set and meet health goalsEvaluating the members environment and support networkCoordinating care and adherence to treatment plans across providers and sites of careConnecting the member to available community support and resourcesAdvocating for the member through their care and life transitionsTo reach that goal, we work with:The member and family/caregiverThe member’s provider(s)The Humana Cares interdisciplinary team and other Humana servicesOther designated resources and community partners
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- #36 DianeThe Model of Care involves the assignment of a member to a primary care manager –a registered nurse This care manager becomes the member’s primary contact. The care team also includes social service and behavioral health specialists, field care managers, community health educators, care concierges and referral specialists.The model of care is robust and fluid. It allows for real time clinical consultations and member reassignments to a higher level of intervention when needed. The primary care managers engage additional resources and support for the member, caregivers, and legal representatives.• Humana Cares Manager-RN – The HCM-RN is a registered nurse with three or more years of clinical experience, along with exceptional communication, interpersonal and technical skills. The HCM-RN assumes responsibility for the management and coordination of care for high risk members. Telephonic contact is initiated, and assessments are completed per protocol on an as-needed basis. The HCM-RN prioritizes member needs, initiates and updates the care plan, engages other members of the care team, and refers to internal and external resources as necessary.• Humana Cares Manager-Social Services and BH – The HCM-SS is the social service, mental health and community resource expert for the telephonic care team. The HCM-SS completes physical, psychological, emotional and environmental telephonic assessments geared toward the appropriate and timely provision of interventions leading to optimal care.• Field Care Manager - The FCM is a registered nurse or social worker. Nurses in the FCM role are licensed with three or more years of experience. Social workers in the FCM role possess a bachelor’s degree in social work with at least five years of experience, or a master’s degree in social work with three or more years of experience. Nurses in the FCM role do not provide skilled nursing care. Both nurses and social workers in the FCM role assess, plan, implement, coordinate, monitor and evaluate the options and services required to meet the member’s health and social service needs. They see the member face-to-face in an in-home setting as needed. This role is characterized by advocacy, communication and resource management. • Community Health Educator – CHE qualifications include at minimum a high school degree, with a preference for some college coursework in the field of health promotion. The college coursework can be substituted with prior experience with health promotion, health coaching, health outreach and wellness education, and/or personal experience with a chronic condition. When personal experience with a chronic condition is the qualifying characteristic, successful self-management skills must be demonstrated. The CHE has a keen knowledge of local, state and national health and social service agencies, community resources, and provider services.
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- #39 DianeHumana Cares provides an integrated complex and chronic long term care management programs for the top high acuity Humana members. Our core Complex Care Management Program identifies participants through the use of algorithms with the most impactable health conditions. The Specialty Condition Management Program supports Commercial and Medicare Advantage members living with one of 13 rare / less common conditions such as Parkinson's, Rheumatoid arthritis and Multiple Sclerosis. Humana Cares supports Humana’s Dual Eligible and Chronic conditions DIA Special Needs Plans members. Humana Cares Chronic Condition Management Program (Disease Management) supports members living with the chronic conditions of diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD).Nurses are key to our clinical programs and look ed to as subject matter experts and mentors.
- #40 Susan ReinhardThank you, Susan, Mary and Diane for these wonderful examples of nurse-led programs in health plans. The programs you described provide opportunities that the Future of Nursing report is recommending; that nurses to take a leadership role in practice and work collaboratively with other health care providers. You can see from the outcomes and case studies described that when there is nurse leadership and interprofessional collaboration, consumer health outcomes are improved. I would now like to open the lines for Q&A Prompt the operator. While waiting for Questions, Here are a few Susan R can pose to presenters:After hearing about the role of nurses and types of programs offered in health plans, how does this inform your work going forward and what do you still need to know about health plans?
- #41 Susan ReinhardCCNA is preparing additional webinars on Nursing Leadership and many other topics throughout the year. Be on the lookout for webinar announcements in Campaign for Action’s Weekly Updates. In September, we will partner with Sigma Theta Tau International and host a webinar featuring nurse leaders who will share how they are leading change and advancing health followingtheir participation in one of the Sigma Theta Tau Leadership Academies.As I mentioned earlier, you can view and share the recording of this webinar and many others by going to www.championnursing.org/events. I would also like to mention that last month, CCNA hosted a webinar in which we presented a Toolkit on “Nurse leaders Nurse Leaders in the Boardroom: The skills you need to be successful on a board.” This DVD toolkit has everything you need for a turnkey presentation that is designed to be presented to nurse leaders nationwide. It highlights the skills and responsibilities of service on a board and what nurses can do to prepare themselves and how to take the first steps. You can visit the link listed here to fill out a request form to receive a copy of the DVD or view the recorded webinar.
- #42 Susan ReinhardThe United States has the chance to transform its system and culture of health care, but only if nurses are better prepared and able to practice and lead to the full extent of their education and training. Through efforts nationally and locally, the Campaign for Action aims to utilize the skills and potential of nurses and nurse champions to effectsweeping change. We need all of you to join us. Together, let’s create a health care system that provides seamless, accessible, affordable and equitable quality care for every American. That concludes today’s webinar. Check us out on the web, follow us on twitter, or join us on Facebook!Thank you and goodbye.