Care Coordination Initiative Helps Patients, Aligns with Quality Measures

Navigator Program Expands to 22 Primary Care Clinics

Memorial Hospital in Gulfport, Mississippi recently completed a successful three-month care coordination pilot with three primary care clinics and is in the process of expanding
the program to all 22 of their primary clinics. Physicians, along with key clinical staff met to determine metrics for measurement and key populations for case management. The workgroup decided to focus on the management of diabetes, hypertension, hyperlipidemia and preventive health screenings.

“During planning, we attempted to align Physician Quality Reporting System (PQRS), Meaningful Use (MU) and Healthcare Effectiveness Data and Information Set (HEDIS) measures as closely as possible with our physicians making the final decision,” explained Melody Griffith, RN, MSN, CCM, Memorial Hospital at Gulfport’s Director, Case Management. The team worked with a data warehouse software application that pulls information from their Electronic Health Record
(EHR).

“We stationed registered nurse (RN) case manager ‘navigators’ within each of the three pilot physician clinics. They used a worklist (from their data warehouse software) that identified patients who were missing key metrics or whose results were undesirable,” said Griffith. “For instance, with a diabetic patient, not only should they have an A1c drawn every three months, their value needs to show good control (8 or less) to prevent unwanted complications.”

The navigators called patients to discuss needed follow up and schedule labs, diagnostics or an appointment with the clinic to address abnormal findings. After a three-month pilot, the navigators had made 1,265 calls to 941 patients, scheduled 510 appointments, 502 labs and 117 diagnostics. And in 330 patients, navigators also identified /documented completed vaccines or scheduled the patient for an appointment to receive the vaccine.

“Our patients were receptive to the calls and open to receiving the needed services,” said Griffith.

“We enjoy sharing successful population management stories, like that of the Memorial Hospital at Gulfport Care Coordination Health Initiative,” said Wallace Palmer, atom QI Advisor. “With the forthcoming changes to Medicare payment, strategies such as those implemented by Memorial Hospital at Gulfport, not only helps patients achieve and maintain better health; it places providers in a position to report and demonstrate that commitment to payers.”

The Medicare Access and Chip Reauthorization Act (MACRA) combines three existing programs, PQRS reporting, Meaningful Use (Advancing Care Information) and the Value-Based Modifier Program into one system to make a new framework for rewarding health care providers for giving better care not more just more care.

atom Alliance works under contract to the CENTERS for MEDICARE & MEDICAID SERVICES (CMS) to improve quality and achieve better outcomes in health and healthcare and at lower costs.