Embedded nurse care managers curb readmissions

Nurse care managers embedded within primary care practices can reduce readmissions, according to early reviews of a New York pilot program.

In the Hudson Valley Initiative, nurse care managers coordinate care for patients with multiple chronic conditions, namely the patients who require a lot of services, GovernmentHealthIT reported.

Six case managers work with eight primary care practices at 13 sites in six counties. The two-year program, which also includes local insurers, will run through 2013.

Early results show "a pretty significant drop in readmissions," according to Annette Watson, senior vice president of community transformation for Taconic IPA, a 4,000-member physician group. Although the pilot is waiting for payer data to validate those findings, Watson, who was also immediate past chair of the Commission for Case Manager Certification, called the results so far, "promising and moving in the right direction."

A key aspect of the pilot is that there is no single, integrated delivery system or single EHR system. The Hudson Valley pilot involves numerous independent providers in an open community, using five different EHR vendors. Though that more closely reflects the reality in healthcare, it poses significant challenges for care managers, Watson said.

A similar project called the Pittsburgh Regional Health Initiative recently was awarded a $10.4 million grant. It also turns to care managers at primary care practices but adds a pharmacist to the mix of professionals. In discharge planning, the pharmacist ensures the patient understands the prescription regimen, then follows up after discharge to reiterate it and assess how well the patient is adhering to it, reported Pharmacist.com.

With the The Centers for Medicare & Medicaid Services adding penalties for readmissions, a flurry of projects are under way to better understand the causes of readmission and how to prevent it.

"We have to find ways to help hospitals and communities address this problem together, as opposed to putting the burden on hospitals alone," Karen Joynt, an instructor at Brigham and Women's Hospital, Harvard Medical School and the Harvard School of Public Health, said in a study announcement in Health Day.

To learn more:
- visit the Hudson Valley Initiative website
- read the GovernmentHealthIT article
- check out the Pharmacist.com report
- read the Health Day article