The month of June finds our Care Coordination programs in full swing. We now have six full time nurse care coordinators (RNCC) to support work at the practice level and provide individualized case management services for the high risk/rising risk (HR/RR) patients. Each nurse meets with their dedicated practices on a monthly basis to update the practice on the work they’ve been doing with their patient caseload and collaborate with the practices on program improvements. The Alliance nurses provide transition of care support for all HR/RR patients who are discharged from a facility – acute care hospital, inpatient rehabilitation center and skilled nursing facilities alike. The goal is to ensure all patients return to a safe place for recuperation and follow the established discharge plan. The nurses also reach out to HR/RR patients who have complex needs or chronic illnesses but have not been recently admitted, to streamline care and support patient self- management activities.

On June 2nd, the RNCC team began documenting their work in Epic so practice personnel and providers now have direct access to the RNCC nurses notes. In Hyperspace or Epic CareLink, look for the Alliance nurse as part of the Care Team, and click on the Notes tab to see the type of nursing services being provided. In addition, you can communicate securely with your designated Alliance RNCC by using the InBasket feature in Epic. Your RNCC will be glad to review the Epic electronic patient record with you on his/her next visit and point out some special features that should make work easier for the entire team.

The first quarter of the revised Care Coordination programs is nearly complete and several new practices have been welcomed to these programs. There are now 28 practices participating in the Commercial Care Coordination program and nine practices committed to the Medicare (NextGen) Care Coordination program. We are beginning to see improvement in our quality metrics and appreciate the energy each practice has devoted to these programs. As a reminder, any of the “gaps” in quality metrics that you have identified as already addressed for Cigna patients can be sent back to the Alliance team to be reconciled with the payor and removed from the “gap” list in the future. This is the only payor group that we can routinely reconcile with at the present time. Successful completion of quality measures for all other payors is done through claims analysis. For participants in our Medicare program, remember to review your lists by the first week of July and send us the names of any patients that are not currently covered by your practice so we can remove them from the list for the remainder of the year (PS: practices participating in the Medicare care coordination program will receive one “point” for reconciling their patient rosters during the first quarter).

Thanks to all who take part in the Care Coordination programs – the RNCC team is excited to partner with practices and work toward the Alliance goals! If you would like more information about the care coordination programs, please contact Joan Snyder at 540-741-2119 or send an email to joan.snyder@mwhc.com.