Background: To ensure efficient and effective care for our rising and high-risk patients, ambulatory care services conducted an analysis of current case management (CM) and direct care registered nurse (RN) services. The analysis revealed primary care CMs and RNs did not work to top of licensure, RN resources were not equitable distributed between sites, and significant variation in services at sites with RNs was found. Leaders also noted RNs who reported to a non-clinical supervisor, which contributed to professional isolation and job dissatisfaction. In response to these findings, executive leadership recommended restructuring CM and direct care nursing services in a centralized model.

Objectives: The purpose of this QI project was to align, standardize, and scale nursing services across all primary care practices in the integrated healthcare system. Services included transitions care management (TCM), HEDIS gap closure, chronic care management (CCM), and RN-led Medicare annual wellness visits (AWV).

Methods: Over an 18-month period, a steering committee of nursing, operational, and physician leaders worked to re-design the structure of CM and direct care nursing services. The committee considered the current workforce analysis, current nursing job descriptions, talent profiles, practice needs, population health needs, patient education gaps, and gaps in nursing care for low and rising risk patient that were not appropriate to be addressed by care managers. The new model centralized nursing services into regional hubs and RNs were assigned a group of practices to support. Assignments were based on geographical location, previous relationship with the RN, provider full time equivalents, patient empanelment, and population needs.

Results: As a result of this initiative TCM call and appointment rates, AWV rates, HEDIS gap closure, STARS, and RN member of the team (MOT) engagement scores improved. TCM call rates increased from 55.7% in December 2018 to 80.1% in September 2021 and TCM hospital follow-up appointment (HFA) rates increased from 23% in 2018 to 50.9% in September 2021, generating 3 million dollars in net revenue. STARs performance for a large Medicare Advantage (MA) population improved from 3.39 in 2018 to 4.6 in 2020. In addition to improvement in STARs scores for this MA population, emergency department (ED) utilization and readmission rates also declined. ED utilization fell from 500/1000 in 2018 to 449/1000 in 2020, and readmissions rates fell from 14.8% in 2018 to 13.5% in 2020. RNs completed over 350 AWV in 2020 and 419 September 2021 year to date. Lastly, RN MOT engagement scores for CM RNs and ICMs saw a 20% increase from 2019 to 2020.

Conclusion: A clear vision and mission is critical for RNs to successfully engage in meaningful CM, TCM, and population health work in a value-based care setting. By aligning primary care RN and CM services under RN leadership and uniting the direct care and CM teams it set the foundation for implementation of evidence-based workflows and programs to improve patient outcomes through shared goals and workflows in a primary care setting.

Erin Brinkley BSN, RN, CMGT-BC

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