The Population Care Coordinator Program would like to welcome the Spring 2017 Visiting Nurse Service New York Cohort:
Jean- Philippe Geralda
to the DUSON family. Their two-day Orientation was held January 26-27, 2017, at the Visiting Nurse Service headquarters in Manhattan, where they completed a comprehensive training in areas of Health Behavior and Motivational Interviewing, Role and Value of PCCP in the Changing Health System, Intro to Population Health, Role of PCCP Education in VNSNY and Evidence-Based Practice. Speakers and presenters included Al Cardillo, executive vice president, Home Care Association of New York State; Rose Madden Baer, senior vice president, Population Health and Clinical Support Services, VSNSNY; and Dr. Noreen Nelson, clinical assistant professor at New York University. Participants will continue their training through a 13-week intensive online curriculum.
The Population Care Coordinator Program would like to welcome Trista Anderson, Cynthia Blakeney, Katora Campbell, Nicole Gholson, Katie Hooven, Laurel Lewis, Mamie Preston, Kerry Silverman and Harriet Sirmons to the DUSON family. Their two-day on-campus orientation was held January 18-19, 2017, at the JB Duke Hotel and Convention Center, where they completed a comprehensive training in areas of Health Behavior and Motivational Interviewing, Evidence-Based Practice, Effective Communication, Care Coordination and an introduction to Population Health. Speakers and presenters included Dr. Barbara Turner, Dr. Isaac Lipkus, Dr. Mary Paden, Dr. Sharron Rushton, Dr. Donna Biederman, Janene Schneider from Alumni Affairs and Carla Nichols from Information Technology. Participants will continue their training through a 13-week intensive online curriculum.
Durham, NC…Duke University School of Nursing and the University of California, Davis Extension are joining forces to bring Duke’s innovative nursing Population Care Coordinator Program to Northern California. Population Care Coordinators are specially-trained nurses who work closely with primary care physicians and care teams to implement patient-centered approaches in health care.
Created by Duke, the 14-week Population Care Coordinator Program is designed to help nurses develop crucial competencies in population health management, care team leadership, health coaching, behavior change and patient self-management. The program will be taught by Duke University School of Nursing faculty with the curriculum localized by UC Davis faculty and regional experts.
“We look forward to working with UC Davis and those Northern Californian nurses who will be at the forefront of delivering high-quality, comprehensive patient-centered care,” said Catherine L. Gilliss, dean of Duke University School of Nursing. “We will work with UC Davis to tailor our educational program to address the health care practices in the region that directly affect the health of patients and their families.”
“By combining Duke’s cutting edge online curriculum and UC Davis’ expertise and knowledge of healthcare in the region, we’re delivering a national program with unique local emphasis,” said Susan Catron, EdD, Director of Health Sciences for UC Davis Extension. “This partnership is a win for everyone – the schools, local health care professionals, and the patients they serve.”
Population Care Coordinators (PCC) empower patients to participate actively in improving their own health care through personalized care that target each patient’s specific health care issues and needs. With support from Population Care Coordinators, patients with chronic illness are able to better manage their health conditions, adhere to treatment plans and, ultimately, avoid costly hospital readmissions or visits to emergency departments.
Training for the program is delivered in an online format supplemented with three intensive face-to-face sessions planned and administered by UC Davis. The first cohort at UC Davis will begin on January 24, applications are currently being accepted. A residency component of the course integrates coursework with skills learned to give students real-world understanding and experience in the role of Population Care Coordinator. The program is also open to other members of the care team who may benefit, including health coaches, health educators and social workers.
The total cost of the program is $3,500. Students who successfully complete the program are awarded a certificate from Duke University School of Nursing and 90 hours of continuing education credit.
For more information about the program at UC Davis Extension, contact Susan Catron at firstname.lastname@example.org or (530) 754-9158.
About Duke University School of Nursing
A diverse community of scholars and clinicians, Duke University School of Nursing is educating the next generation of transformational leaders in nursing. We advance nursing science in issues of global importance and foster the scholarly practice of nursing. In 2011, U.S. News and World Report ranked Duke among the top seven graduate schools of nursing in the nation. The School offers masters, PhD, and doctor of nursing practice degrees, as well as an accelerated bachelor of science in nursing degree to students who have previously graduated from college.
About UC Davis Extension
UC Davis Extension, the continuing and professional education division of UC Davis, has been an internationally recognized leader in educational outreach for individuals, organizations and communities for more than 50 years. With nearly 50,000 annual enrollments in classroom and online university-level courses, UC Davis Extension serves lifelong learners in the growing Sacramento region, all 50 states and more than 100 countries.
Thousands of primary care practices have taken the plunge and become recognized as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). Many have found the process of transformation to be a challenging but rewarding experience.
Among the innovations practices employ, there is a strong focus on:
- patient management during transitions of care to decrease readmission;
- scheduled, proactive outreach to high-risk patients; and
- initiatives that support patient self-management of chronic diseases.
To facilitate these “pillars” in the medical home, PCMHs have hired care coordinators to create new workflows that integrate these activities into the team approach. This supports collaboration with already overburdened providers, and encourages medical assistants to contribute in a more valuable way to the patient visit.
I am the director for care coordination at one such practice, Vanguard Medical Group (VMG) of Verona, N.J. We have four care coordinators across three locations, which has helped the practice improve outcomes and maintain the NCQA PCMH recognition it first earned in 2009. We leverage tools such as healthcare communication networks and the practice’s EHR to help the care team — made up of physicians, mid-level providers, medical assistants and a diabetes educator — manage patients with complex needs, design standardized treatment plans across the sites, and encourage patient engagement.
Among other benefits, this process has produced decreased utilization rates. One of our local facilities has a 25 percent lower hospital readmission rate than our local peer practices. As data exchange and care quality requirements like these increase, technology-equipped care coordinators will become more integral to achieving success in PCMH programs.
Stephanie Celani not only knew the phone number of her patient John Pantalone, she also knew his weight to the half-pound when asked one day this month.
That’s because Celani, a registered nurse at Advocare L.L.C., a 380-member physicians group in Marlton, has been Pantalone’s care coordinator for the last five months, since he was laid low by a serious infection acquired at a rehabilitation hospital.
Celani calls Pantalone, 70, of Marlton, almost every day for information, such as his weight, blood pressure, and a figure that shows how his transplanted kidney is working. Celani reports any deviations to Pantalone’s doctor.
During the most intense period of Pantalone’s recovery, “Stephanie was becoming like a family member. She would call me every morning” and ask for the “magic number,” his weight, Pantalone said.
The purpose of all those calls is to keep Pantalone, whose health problems spiked in the fall when he had renal failure and collapsed lungs after heart surgery, from landing back in the hospital.
Pantalone is experiencing firsthand a push by
Advocare and Horizon Blue Cross Blue Shield of New Jersey – in accord with national efforts – to trim spending and improve quality by proactively approaching care, especially for high-risk patients.
Under the program, which Advocare started in August, the practice has a strong incentive to cut the total cost of care: Horizon lets Advocare keep half of any saving.
The program represents a major shift for doctors.
For a long time, physicians have known the costs of their own services, said John M. Tedeschi, a pediatrician and founder of Advocare, “but they never added the other piece.”
“What was I spending on hospitalizations? What was I spending on radiology? What was I spending on specialty referrals? What was I spending on five million other things that go into health-care costs? Now we’re going to have that whole picture,” Tedeschi said.
An early focus at Advocare, which has doctors in all of New Jersey and in Southeastern Pennsylvania and which is among the nation’s largest independent physicians groups, has been reducing the frequency of hospital readmission of its patients within 30 days of discharge, an area of health care under laser focus nationally now that hospitals are being penalized by Medicare for excess readmissions.
Advocare is not a hospital, but its Horizon contract gives it a financial incentive to reduce readmissions under the insurer’s most advanced shared-savings program, said Jim Albano, Horizon vice president of network management and Horizon health-care innovations.
In a collaboration between Duke University School of Nursing in Durham, North Carolina, Rutgers College of Nursing in Newark, New Jersey, and Horizon Healthcare Innovations, also in Newark, the PCC certificate program will train 200 nurses over the next two years. Students will complete 12 weeks of classroom, online, and hands-on training based on a curriculum developed by nurses at Duke, followed by a 160-hour preceptorship coordinated by Rutgers.
The first 200 PCCs trained will be placed in primary care practices in New Jersey, but it’s anticipated that the curriculum could serve as a national model.
PCCs help to identify high-risk and clinically complex patients in the primary care practice and coordinate care between the medical home and the community. “The focus is on chronic illness management, disease prevention strategies, health promotion interventions, and transitional care needs,” says Diane L. Kelly, assistant clinical professor at Duke.
Asked how the role of the PCC differs from that of the public health nurse, Edna Cadmus, clinical professor and specialty director of the graduate leadership track at Rutgers, explains, “Public health nurses are looking at the population level and determining the cause of health problems in a community to find ways to prevent them. PCCs are dealing with the individual patient, creating plans of care with the interdisciplinary team, as well as looking at the population for that practice in aggregate” and identifying high-risk conditions for which outcomes could be improved. They then develop systems and programs to support that high-risk population.
On Feb. 1, Rutgers University School of Nursing in Newark, N.J.; Duke University School of Nursing in Durham, N.C., and Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, announced the launch of a nursing collaborative to train nurses as population care coordinators in New Jersey. During the next two years, at least 200 nurses will receive education as PCCs to work in a patient-centered medical home program and other population-based health programs.
“The PCCs will serve as pioneers in implementing this new model in the state. Through this unique partnership, we are looking to shift care delivery from an illness model to one of keeping our citizens healthy,” said Edna Cadmus, RN, PhD, NEA-BC, clinical professor and director of the DNP program-leadership track at Rutgers. “The PCCs will serve as linchpins to analyzing data on high-risk patients and developing coordinated plans of care.”
PCCs assess the needs of high-risk patients and close the gaps in their care. Working with primary providers in the medical groups, they follow up on preventive and wellness strategies and arrange appropriate consultations.
“As a PCC, I connected a patient with Alcoholics Anonymous and expedited another patient, who was in acute distress, to receive preadmission testing and cardiac clearance prior to surgery,” said Janet Duni, RN, MPA, PCC in the Vanguard Medical Group in Verona, N.J. “Upon reviewing one patient’s medications, I discovered that he was double-dosing, and we discarded 18 expired medication bottles. After updating his medication list, I enrolled him in an automatic three-month reorder medication service through the Veterans Administration.”
At an accelerating pace, the nation’s health insurance companies are embracing the latest trend in care delivery: An ounce of prevention is worth a pound of cure.
Last month, WellPoint Inc. said it would increase payments to physicians who transition to patient-centered medical homes. Some observers believe the announcement by one of the nation’s largest commercial health insurers, covering 34 million lives in affiliated plans, represents a seismic shift in the movement toward coordinated care and preventive medicine.
The plan calls for care management fees for primary care physicians, who could see fee increases of about 10% with incentives that could improve payments by as much as 50%.
And in another sign that the landscape is shifting, Horizon Blue Cross Blue Shield of New Jersey this month announced that it would fund a collaborative to train 200 nurses in the Garden State over the next two years as “population care coordinators.”
Horizon Healthcare Innovations, a subsidiary of Horizon BCBSNJ, said the “first-of-its-kind initiative” is designed for nurses who work in primary care physicians’ offices. The program uses curriculum developed in collaboration with Duke University School of Nursing and Rutgers College of Nursing.
Horizon Healthcare Innovations partners with Rutgers and Duke to educate RNs.
A new crop of nurses is being trained as population care coordinators — nurses who serve as part coach, part health advocate to improve coordinated follow-up and preventive and wellness care.
The program is a collaboration among Horizon Healthcare Innovations (HHI) and its education partners Duke University School of Nursing and Rutgers University College of Nursing.
It’s attracting nurses like Janet Duni, who has been working for the past year as a population care coordinator at Vanguard Medical Group in Verona.
“I manage the most high-risk population in the practice,” she said, those with chronic conditions like diabetes and heart disease. “I reach out to patients who have had a hospital discharge or an emergency room visit, to make sure that they are at home, that they are settled, that their medications are correct. If they need a follow-up appointment with a doctor, I make it.”
Duni, with 30 years experience as a nurse, including in the emergency room and intensive care, began the new 12-week training course in January, a combination of online and face-to face-instruction that focuses on case management using databases, skills Duni will use for the care she coordinates for 5,000 Vanguard patients who are Horizon members.
The training is funded by HHI, a new company launched in 2010 by Horizon Blue Cross and Blue Shield of New Jersey. “We are creating a new nursing leadership role that will support New Jersey’s primary care doctors and deliver improved care to patients,” said Christy Bell, chief executive of HHI.
Dr. Richard Popiel, president of HHI, said the company has been funding the hiring of population care coordinators since launching a patient-centered medical home pilot program more than a year ago with eight primary-care practices. That pilot was expanded with an additional 15 practices in January, and now involves about 80,000 patients. The curriculum to train more coordinators grew out of the work that has already begun in the medical practices.
“This gives us a great opportunity to formalize the education around what they are going to be doing in these practices,” Popiel said. “This is something nurses have not been taught in traditional nursing schools.”
At a press conference Wednesday at the Rutgers School of Nursing in Newark, Popiel said HHI is investing more than $1 million to train 200 nurses over the next two years. The nurses will work in medical practices that are partnering with HHI, which is both paying the cost of training the nurses, and providing additional payments to the medical practices so they can afford to hire the nurses.