It is commonly known that approximately 80 percent of healthcare costs are spent on caring for about 10 percent of a health plan’s participants.

 

These individuals – typically elderly or disabled patients with multiple chronic conditions – are increasingly participating in medical home programs, which aim to improve health outcomes and generate savings for patients and health facilities.

 

Mary Ellen Gervais, PhD, RN, CCM, vice president of InforMed Medical Management Services, is involved in the ongoing development of an integrated case management software system that targets and helps manage the 10 percent of patients that account for the majority of healthcare spending in the U.S. This software, one of InforMed’s main products, guides case managers and nurse navigators in evidence-based case management to measure health outcomes.

 

Gervais, a registered nurse with more than 20 years of case management experience, is a faculty member on the upcoming Dorland Health/URAC webinar, Boosting Outcomes in the Medical Home Through Case Management, on Jan. 26 at 2 p.m.

 

To get a deeper understanding of the software she helped develop, Medical Home Today sits down with Gervais, who also discusses the role of the case manager in the medical home model.

 

Mary Ellen Gervais: Our software is the InforMed Data Warehouse and Medical Management Outcomes Tracking System (MMOTS). Among other attributes, the InforMed system promotes clinical productivity, quality, and standardization of practice. It was built on principles related to CMSA Standards of Practice, URAC Accreditation Standards, and outcomes research.

 

Two portals are also available in the system. The provider portal provides integrated information on an individual participant level as well as a provider population level. The InforMed risk stratification and evidence-based medicine applications are integrated into the portal to provide population level information to each provider.

 

The participant portal provides the participant access to the integrated information accessible by the provider and the personal health nurse as well health information specific to their needs. The portal provides the participant with the option of enhancing their information with health history and other health related information not populated from other sources. 

 

Gervais: Our experience with working with physicians and assisting in the development of medical homes has shown that there are two primary obstacles to physician engagement in these initiatives. The first is related to the availability of information. The second is related to the availability of the physician’s time. In the InforMed model, both of these are addressed. Extensive and integrated information is available to the entire medical team, as well as to the participants themselves. In addition, the availability of the personal health nurse to the physician helps with follow-up that is often not possible for the physician. The personal health nurse also is able to coordinate needed additional services to support the medical management plan. 

 

Gervais: With attention to the high and moderate risk participants, health plans have usually seen a financial impact shortly after the patient-centered medical home initiative has been started. As the personal health nurse continues to address the high and moderate risk needs, cost savings continue. As the personal health nurse and the provider work together to address gaps in care for the provider population, longer term impact on cost occurs as improvement in adherence impacts clinical status. 

 

Gervais: As the nurse is working to support the treatment plan, coordination of necessary services becomes key. This coordination occurs very often during transition periods. Active participation by the nurse during these periods results in successful transition and a decrease in readmission to higher levels of care. In addition, one of the key roles of the nurse in the medical home is to support the health management plan. One of the key approaches to this is the establishment of open communication and an effective relationship between the nurse and the participant. As a result of this relationship, the nurse becomes an integral resource to the participant. The participant will likely access this resource during transitions.

Gervais: The personal health nurse is aware of the holistic needs of the participant. The personal health nurse educates on the management of their condition, coordinates educational classes and supports, and coordinates other community resources including. The personal health nurse helps the participant identify their goals as well as barriers towards achieving those goals. As a part of the personal health support, services are coordinated to help address the barriers. Access to the personal health nurse is provided on an ongoing basis to support achievement of participant goals. On a population basis, the personal health nurse works with the provider to review the system in terms of population gaps in care related to the management of chronic conditions. The nurse also works with the provider to strategize on population support and education for the management of chronic conditions.