Why Should we pay for care coordination?

A friend of mine has a masters degree in social work she can hang her shingle up and get paid for her services by insurance; but we can't. As a private care coordination service we are not paid by insurance. Regardless of the fact that I have a Masters Degree also along with being a licensed registered nurse I cannot be paid for care coordination/case management.

It is clear in our practice that what we do works.  Over an 8 year period we have NEVER has a client readmitted in the hospital in 30 days.  The reason, for us, is simple. We have one person in charge, the communication is clear and concise with primary physicians, we coordinate between all teams involved, we monitor and are engaged with our clients and families and we know when to act.

Care coordination; especially by registered nurses, have been proven to have excellent outcomes. According to an integrative review, Joo (2014) identified that nurse-led, community-based, case management led to overall reduction to hospitalization  and readmissions; and positive client-focused outcomes (e.g., improvements in quality of life, greater symptom control, better patient satisfaction). According to the American Nurses Association (ANA) "the value of RNs in care coordination has been demonstrated in numerous studies and healthcare reform and initiative." (ANA, 2012). The ANA (202) has concluded that RNs provided the following benefits to patients and providers of care coordination services:


Reduced Emergency Department Visits

Decreased medication costs

Reduced inpatient charges

Reduced overall savings per patient

Decrease mortality

Reduced readmissions

Lowered total annual Medicare costs for beneficiaries

Increased patient confidence in self-management of care

Improved patient satisfaction with care

The ANA summary from multiple research studies provides ideas for outcome measures for future nursing research of new models of care coordination. These outcomes can be captured and tracked in electronic health records associated with patient care, and may be especially useful to measure outcomes of complex care of older adults with multi-morbidity. Developing standards for care coordination and defining successful outcomes will continue to be challenging. Answers to the challenging questions are needed for policy-makers who arrange payment for state Medicaid and federal Medicare;as well as for healthcare system leaders including insurance executive and hospital leaders.  The complexity inherent in our healthcare delivery system makes evaluating the cost effectiveness of care coordination challenging. Reducing cots, while also maintaining or improving a positive patient experience and positive client outcomes, offer the greatest likelihood of program sustainability (Browdie,2013)

Effective communication with patients as well as with members of the care team was identified as essential across many studies associated with RN care coordinators (Berry, et al, 2013: Ehrlich et al.,2012;Skillings & MacLeod, 2009)

Care coordination is a team sport and other providers are needed to achieve high quality, cost effective services. Again, this may be especially true in the complex cases of older adults with multimorbidity. Other members of the team each have a role to play in meeting an individual’s needs across the continuum of care. For example, team members may include a pharmacist to help with medication management; a disintegration of the care coordination model. Physical therapist to help improve functional status disintegration of the care coordination model. physical therapist to help improve functional status; a social worker to address the psychosocial needs of an older adult; and a physician to manage the medical diagnosis and medical plan of care. Social workers have been designated as an essential partner for the advanced practice nurse in the Geriatric Resources for Assessment and Care of Elders (GRACE) model of care coordination (Counsell et al., 2006). A social worker may be most appropriate for managing patients with predominantly psycho-social issues. Specific psychosocial needs of an older adult, such as arranging transportation; extended care; mental health services; and other services to support non-medical health-related needs, often fall under the purview of social workers. 

 A Practice-Based Model of Care CoordinationSetting: A large, physician-owned, primary care practice in the Midwest. All primary care sites in this practice are Patient-Centered Medical Home  (PCMH). The practice consists of three certified offices, including primary care practices for Internal Medicine, Family Practice, and Pediatrics. Background: In 2014, the practice began care coordination for the high risk patient population in the outpatient setting. The evidence-based model in use consists of a team that includes RNs and master’s prepared social workers who collaborate extensively. The organization specifically designed this model with a social worker to augment the RN care coordinator nursing role with a professional who has expertise in addressing psycho-social needs and barriers to care that high risk patients face every day (e.g., transportation, financial concerns, housing issues).Preliminary Evaluation: This practice model, now in its second year, is working well. Social workers, in many instances, can be busier than the nurses. To successfully prevent hospitalizations and readmissions, the basic hierarchy of needs is first addressed with the special background and experience of the social worker. Once these needs are met, the RN care coordinator has a better chance of changing behaviors in some patients through education and management of co-morbid conditions.The versatility of the RN role means that he or she is often the professional whobridges gaps between the complex patient’s mental and physical needs.Elder-Appropriate Models of Care Coordination Models of care coordination areprograms that provide a consistent structure for coordinating and organizing care for older adults. bridges gaps between the complex patient’s mental and physical needs. As described above, each team member brings unique professional expertise to the care of individual patient needs. These specific needs are the deciding factors that inform the decision about who participates on the care coordination team. Researchers have concluded that RN nursing judgement was a positive factor to decide how best to use resourcesassociated with models of care coordination and whether a patient would benefit from care coordination (Ehrlich et al., 2012). The next section will describe some models of care coordination particularly relevant to caring for elders.Models of care coordination are programs that provide a consistent structure forcoordinating and organizing care for older adults. The program will help the older adult have a reliable resource person and interface within the healthcare system to assure that all services are accessible and there are no redundancies indiagnostic tests. The program provides a hub for all communication about theperson’s health (e.g., diagnostic test results, medication regimen, medicalconditions, plan of care).Reducing costs of care associated with older adults is often measured by decreasing the number of hospitalizations, because hospitalizations are the most expensive part of the care trajectory. Over the first four years of the  demonstration, only two of the 15 programs met the goal of reducing hospitalizations. After an additional two years of study, and through use of an increased sample size of Medicare participants in the remaining 11 pilots, two new programs were identified, for a total of four programs that significantly reducednumber of hospitalizations. These four programs all had RNs as care  coordinators (Brown et al., 2012).

It's clear that the status-quo isn't working. The need to incorporate those who work out of the self made fortress of the healthcare system is needed more than ever. Having hospitals, physician practices, nursing homes, assisted living communities, dementia units start to utilize the talent that I believe that exists in the frontier need to be brought in to assist with what is a disturbing trend and cycle of patients in patients out patients die patients live. No one is happy not those entering and not those working.

If insurance looked at how others are working and incorporated a fee structure for those who have great credentials to help should be considered. Nurses know how to coordinate care better than any. Use them right and you have a gold mind of only positive outcomes. Stop wasting the resources that are in front of you!!