Medical Homes

Population Care Coordinators: A Key to Improved Care at Lower Cost?

In New Jersey, Horizon’s patient-centered medical home program puts data-savvy nurses in primary care practices to reach out to high-risk patients and forestall costly crises

Timothy Kelley
Senior Contributing Editor

Trying to save money in health care isn’t new to Sandra Siegel, RN. A nurse with 30 years’ experience, she remembers working for a managed care company in the ’90s doing precertifications and checking hospital stays.

“I worked with algorithms that said things like, ‘Patient A is going to have this surgery and get four days in the hospital,’” she recalls. “And if the person didn’t go home in four days, I had to figure out why. It was very, very stressful.” Today Siegel has a job she likes much better. And there’s every chance she’s saving more health care dollars now than she did back in the bad old days.

Sandra Siegel, RN

“Two years ago, when I started, having a care coordinator in the office was a very new concept,” says Sandra Siegel, RN, of Hunterdon Healthcare Partners. “Well, have things changed in two years!”

Siegel is a population care coordinator employed by Hunterdon Healthcare Partners (HHP), a for-profit arm of Hunterdon Medical Center in Flemington, N.J., that manages its integrated delivery system and forms an accountable care organization (ACO) under the Affordable Care Act (ACA).

Though HHP cuts her paycheck, Siegel is closely linked to two other entities: She spends her days “embedded” in a Hillsborough, N.J.-based primary care practice called Your Doctors Care, and she’s part of an initiative sponsored by Horizon Blue Cross Blue Shield of New Jersey, the Garden State’s largest health insurer with 3.7 million members.

Horizon BCBS runs the state’s largest patient-centered medical home (PCMH) program, of which roughly 200 population care coordinators statewide are a part. At Your Doctors Care, she works with a patient panel mainly of Horizon members. But physicians and patients alike know one thing about Siegel: She’s not the enemy.

“My impact now is much greater than it was in my old job because I get to talk to patients,” she says. “I get to find out what barriers they face — barriers to being compliant with medications, for example — and determine what we can do to help them take better care of themselves. Because if you don’t drill down and find out what’s really going on, you’re not going to make a difference.”

Siegel and her fellow coordinators in the Horizon program play a vital role in the effort the insurer is making, in common with many of its fellows across the country, to deliver timelier, more effective, less wasteful care by turning the primary care practice into a PCMH — “one point of contact for all your health care needs,” as a Horizon BCBS brochure tells its members.

Reinventing primary care

Horizon BCBS’s goal in launching its PCMH program, says Carl Rathjen, manager of network strategy and program development, was to promote a culture of change in the primary care practice. Change has certainly been in the air nationally, with the ACA and every expert calling for a new emphasis on prevention. And if that weren’t enough, the need for a change in primary care was also suggested by the field’s scary demographics, with dwindling numbers of medical school grads choosing primary care specialties and pros in the field burning out faster than their specialist colleagues.

Carl Rathjen

“Horizon wants to promote a culture of change in primary care practices, says Carl Rathjen, the health plan’s manager of network strategy and program development. That was one of the insurer’s goals in launching its patient-centered medical home program.

In the PCMH model, as a 2012 Health Affairs article by Rathjen and two Horizon colleagues put it, “Primary care becomes the focal point for the delivery system because of its ability to provide patient-centered, comprehensive coordinated health care to patient populations — care that goes beyond the mere provision of basic services.” To bring costs down and quality up, the theory goes, doctors’ offices on a vast scale must stop simply waiting for patients to come in the door and start proactively managing their health.

That’s what Siegel tries to do, working with other staffers at Your Doctors Care. “I never do the same thing two days in a row,” she reports with satisfaction. But the thrust of what she does each day is to reach out to high-risk patients before they have an expensive medical crisis so they can get the care they need to head that crisis off. “A lot of it involves keeping people out of the hospital,” says Siegel. “That is, keeping people healthy so they don’t need to go to the hospital.”

Patients are stratified according to risk based on claim reports provided to practices monthly by Horizon, and people rated at the highest risk levels become the subject of outreach. Explains Siegel: “We can run a report on our hypertensive patients, our diabetic patients, or our patients with congestive heart failure and ask, ‘Are they coming in for their scheduled appointments? Are they getting the care they need?’ For example, we might say, ‘How about Mary Smith? She’s multimorbid, Level 5, yet she hasn’t been in for six months. Why not?’ We don’t just wait until she gets sick. Mary gets a call.”

Rathjen says that “The core concept of this model is to strengthen the relationship between our members and their physicians through payer-provider collaboration.” Indeed, one mark of this collaborative approach is that risk scores aren’t just handed down to practices like edicts from on high; the doctor, who knows his or her patients, makes the final decisions.

Mary Aikins, RN

Mary Aikins, RN, of Horizon, says, “We hear frequently about the difference population care coordinators make.” Both patients and doctors value the PCMH effort, she adds.

Explains Mary Aikins, RN, Horizon’s manager of care management operations: “The doctor takes the risk scores we provide for patients based on claims data and asks, ‘Do I as the physician agree that they’re high-risk?’ So claims information isn’t the be-all and end-all. The doctor may say, ‘I know Joe Jones had a lot of claims last year, but that was because of a back injury that has been resolved; he’s now healthy. But 55-year-old Al Clark, who doesn’t exercise and has a tough family heart-disease history — I call him high-risk even though he doesn’t yet show up in your claims data.’ So it may be Clark who gets contacted.”

PCMH designation

Specifically, it’s a division within Horizon called Horizon Healthcare Innovations (HHI) that runs the insurer’s four-year-old PCMH initiative. To be part of the program, Horizon encourages practices to work toward designation as a PCMH from an accrediting body such as the National Committee for Quality Assurance, URAC, or the Joint Commission.

That means, of course, that they agree to use electronic medical records and provide the data necessary to evaluate care. They also must have evening and weekend hours — and round-the-clock access to physician advice — to minimize emergency room visits.

When a practice meets these responsibilities and is allowed to participate, Horizon provides initial and ongoing training for the coordinators. Siegel remembers taking a rigorous 12-week graduate course in population care coordination given at Duke University School of Nursing in Durham, N.C., in collaboration with Rutgers University School of Nursing in Newark.

Horizon has since designed its own two-day, in-state learning collaborative to offer the program more frequently to incoming population care coordinators. These sessions include training on Horizon-developed tools to support population management.

Horizon also pays practices a monthly care coordination fee to subsidize the coordinators’ paychecks. That fee is reduced after the first two years, but by then the successful practice is earning more by meeting tough benchmarks for quality, utilization, and patient experience.

New role for nurses

“It’s one of the distinctive features of our program that we require these population care coordinators to be registered nurses,” says Aikins, who has 17 years’ experience running a case management company and was involved in planning the coordinator role for Horizon from the beginning.

Indeed, agrees Steven Peskin, MD, HHI’s senior medical director, this unusual use of nurses is a potential model for other health plans. “Nurses have been working in similar roles for hospitals and large integrated health systems for years,” he says. “But we think it’s novel that a payer has implemented this RN function that operates within primary care practices.” (Full disclosure: Peskin is a former executive vice president and chief medical officer at MediMedia USA., which publishes Managed Care.)

Steven Peskin, MD

“We think it’s novel that a payer has implemented this RN function that operates within primary care practices,” says Steven Peskin, MD, the senior medical director at Horizon Healthcare Innovations.

“This is a very distinct role from what nurses traditionally have done within the managed care industry,” agrees Rathjen. “As care coordinators, these nurses actively engage the patients to keep them healthy, not just speak to them when they are sick.”

Nurses have both the clinical authority and the people skills to build the necessary trust with patients, he says. “We wanted people with significant clinical expertise who could communicate with patients so that patients would act on what they recommend.”

Says Aikins: “In many situations, patients prefer to be engaged with, as opposed to being ‘managed’ or ‘directed’ in the traditional insurance-company case-management or utilization management functions — although we have those too.”

It started with eight

Horizon’s PCMH program began in 2009 with an initial focus only on patients with diabetes. Some 33 practices qualified to participate. Costs were reduced, but as the Health Affairs article explained, “the reduction was not enough to cover all of the up-front costs incurred by Horizon.” In discussions with the New Jersey Academy of Family Physicians and participating doctors, the insurer decided to put more chips on the table. It designated just eight practices as participating PCMHs and assigned each a population care coordinator to work not only on diabetic patients, but on all patients. At that point, the coordinators were direct Horizon employees.

“I started with eight nurses,” Aikins recalls. “Back then we didn’t have a lot of the reports we have today, and we had to develop a training program. We’ve moved away from Horizon being the employer; now we provide a subsidy and the population care coordinators are employed by the practices.” In cases like Siegel’s, they are employed by an integrated delivery system.

With initial results promising, the program was “scaled up” to where it now involves about 200 practices around the state. And as Peskin points out, Horizon “continues to support the participating practices with training and mentoring.”

The culture change didn’t happen overnight, and it wasn’t all the population care coordinators’ doing. Every member of the PCMH practices learned to do his or her part to facilitate proactive care. And everyone faced a learning curve — including doctors. “Two years ago, when I started, having a care coordinator in the office was a very new concept,” says Siegel. “Doctors and office staff weren’t sure what to do with us. Well, have things changed in two years!”

Today, she says, “our front-office staff has been educated. They do a fabulous job of helping to identify high-risk patients when they call or come in and helping us triage and figure out what’s going on.”

The idea, as Aikins explains it, is to have every member of the practice staff working to the top of his or her license.

“We work as a team,” says Siegel. “The coordinators don’t direct care or come up with treatment plans, but the doctor may say, ‘Why don’t you sit down and do some diabetes education with this patient?’ Or it may be hypertension or weight-loss counseling.”

Data from 2013, released in July, suggest that the Horizon PCMH program is making a difference. (See “But Does It Work? The Horizon PCMH Record” below.) And Siegel offers anecdotal evidence that her workdays now are not only more satisfying, but also more effective than were her struggles to limit hospital stays back in the ’90s. She recalls with satisfaction that when one patient was having a crisis that was beyond what her primary care practice could deal with, she got on the phone and invoked her relationship with Hunterdon Medical Center. Such is Siegel’s concern for the patient privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) that she declines to identify even the specialist’s clinical area, but she got the person in to see the appropriate specialist within three hours.

But does it work? The Horizon PCMH record

To date, there is no clear evidence that the [patient-centered] medical home improves the quality of care or reduces the total cost of care,” wrote Horizon Blue Cross Blue Shield staffers Carl Rathjen, Urvashi B. Patel, and Elizabeth Rubin in Health Affairs in 2012. But today — with a hefty assist from “population care coordinators” based in primary care practices who combine RN credentials with special population-care training — they and their colleagues are working hard to change that. And the favorable evidence is starting to come in.

As the company reported in July, a study of 2013 claims data for more than 200,000 members compared PCMH patients with a similar set of patients in traditional practices. The PCMH patients showed a 14% higher rate of improved diabetes control, a 12% higher rate of effective cholesterol management, an 8% higher rate of breast cancer screening, and a 6% higher rate of colorectal cancer screenings.

The contrast was less sharp when it came to reducing costs, but here too the PCMH practices did better. The rate of hospital admissions for the latter group was 2% lower, while the number of emergency room visits, the cost of care for diabetic patients, and the total cost of care were all 4% lower for the PCMH group.

Said Horizon: “Members under the care of a patient-centered practice were also able to avoid more than 1,200 emergency room visits and 260 hospital admissions, which represent a savings of approximately $4.5 million.”

Similarly, Aikins says another population care coordinator was making a routine phone call to follow up on a patient who hadn’t had her mammogram or other recommended screenings. “The coordinator introduced herself, said she was calling from Dr. So-and-so’s office and explained her role,” she says, “and the patient mentioned that her brother had recently passed away, and that she hadn’t been feeling well and had been meaning to make an appointment with the doctor. It turned out she had multiple blocked arteries, and two days later she had three stents put in. The coordinator’s routine call very likely saved her life.”

This new professional’s role may not by itself be a panacea, but Horizon’s position is that it is part of the answer to transforming primary care, which in turn can be the key to making health care leaner, more proactive, and more effective.

“We hear frequently about the difference population care coordinators make,” says Aikins. “We hear it from practices and we hear it from patients.”

8 qualities a coordinator needs

Sandra Siegel, RN, a population care coordinator in the patient-centered medical home program of New Jersey’s Horizon Blue Cross Blue Shield, is clearly a people person, but she also has an affinity for quantitative thinking. “I like data,” she declares.

Because coordinators like her may have a role to play in improving health care nationally while containing costs, Managed Care asked Siegel what qualities are required for success in a job like the one she’s now held for two years. She says a population care coordinator must:

  • Have a strong, well-rounded nursing background and general health care knowledge.
  • Be a kind, caring person.
  • Be a good listener, attuned to what patients are telling her or him (even sometimes “in between” the words they’re explicitly saying).
  • Understand data and how to interpret it.
  • Be familiar with electronic medical records.
  • Be comfortable speaking in medical terms with providers and in lay language with patients, and switching rapidly between the two.
  • Know the community, its transportation system, its services for the disabled, its nursing homes, its clinics, its hospitals, and their departments such as emergency rooms, radiology facilities, etc.
  • Be intuitive, creative, and able to “think out of the box.”

The author was editor of Managed Care from 1995 through 1997.