CMSA Today - Issue 4, 2021

PRIMARY CARE

EMBEDDED NURSE CASE MANAGERS IN PRIMARY CARE: MY EXPERIENCE AND STRATEGIES FOR SUCCESS BY KELVA EDMUNDS-WALLER, MSN, RN, CCM

I ntegration of nurse case managers in primary care is an increasingly popular population health strategy to improve healthcare quality, reduce healthcare costs and improve the patient experi ence. Case managers are intuitive thinkers able to assemble information from various sources and quickly see the “big picture.” This type of thinking enhances their ability to connect relationships, develop strategies to solve problems and modify plans as situ ations evolve and change. Case managers are also analytical thinkers and use data from multiple information sources to identify and prioritize patient care challenges and be deliberate and focused in finding solutions to new and reoccurring problems. Intuitive and analytical thinking, clinical experience and using case management processes and stan dards of practice make nurse case managers an excellent fit as embedded case managers in primary care. CLINIC PROFILE I have been an embedded case manager in a primary care resident clinic at an aca demic medical center for approximately 2 years. The clinic has 71 residents who rotate through the clinic and 13 attendings provid ing resident supervision. The interdisciplinary team includes registered nurses, licensed practical nurses, medical assistants, clini cal pharmacists, psychology fellows, social workers, a diabetes educator, an outreach worker, two medical directors, a nurse man ager, a clinical coordinator and administra tive staff. The clinic provides care to over 1,800 patients. Approximately 62% of the clinic population is Black, 28% white, 10% comprise American Indian-Alaskan, Native

Hawaii/Pacific Islander and unknown ethnici ties. Hypertension, heart failure, diabetes, CKD and COPD are among the top diagnoses seen in the clinic. Like many primary care clinics, patients often have several co-morbid conditions impacting their health. Limited health and reading literacy and other social determinants of health, including mental health, are additional factors that contribute to a moderate to highly complex patient population in the clinic. A TYPICAL DAY IN PRIMARY CARE The primary goals for embedded nurse case managers include chronic disease management and avoidance of hospital readmissions. I currently manage about 55 patients in the resident clinic. On a typical day, I begin by reviewing discharge reports, including patients discharged following an ED or inpatient admission. Transition of care (TOC) assessments account for 50% of my workday. On average, I complete TOC assessments on five patients per day. Assessments are comprehensive and focus on reviewing discharge instructions, medica tion review and management, scheduling follow-up with the primary care and spe cialty providers and coordinating recom mended diagnostic tests and procedures. Screening for social determinants of health is also a component of each assessment. Social determinants that frequently impact the patient’s ability to follow the care plan include access to care, income insecurity, limited reading and health literacy. Medication management involves resolv ing medication discrepancies, assisting patients in obtaining medications, teaching patients about each medication’s purpose

and how to self-administer medications. Due to income insecurity or payer require ments, a call to the provider may be neces sary to communicate that a medication is not covered or unaffordable for the patient. If an alternative medication is not available, I initiate prescription assistance program applications and follow up to help patients obtain prescribed medications. If a patient cannot self-administer medications indepen dently, I engage appropriate family members for assistance. Some patients come into the clinic for assistance with reading prescription labels to fill pill boxes correctly. Medication management also involves following up with patients after a scheduled appointment to review any medication changes. Typically, providers do not have time to follow up with patients to ensure adherence to medica tion changes. So, this is an essential role of embedded case managers. It may be necessary to coordinate post acute care services (i.e., home health, remote patient monitoring) following a hospital discharge. Involvement of post acute care services requires ongoing fol low-up and collaboration to evaluate the care plan’s effectiveness and make revisions as needed. To reduce or prevent hospital readmissions, I follow up with patients or caregivers weekly during the 30-day transition periods to assess the patient’s health status and proactively manage any problems that may negatively impact the care plan. Regular communication with the primary care provider and other team members occurs to ensure that the team has updated information on the patient’s health status. Referrals to psychology, social work and community outreach to address social

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CMSA TODAY

Issue 4 • 2021