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NJ Nurses Train to Coordinate Their Patients' Care

Horizon Healthcare Innovations partners with Rutgers and Duke to educate RNs.

A new crop of nurses is being trained as population care coordinators -- nurses who serve as part coach, part health advocate to improve coordinated follow-up and preventive and wellness care.

The program is a collaboration among Horizon Healthcare Innovations (HHI) and its education partners Duke University School of Nursing and Rutgers University College of Nursing.

It's attracting nurses like Janet Duni, who has been working for the past year as a population care coordinator at Vanguard Medical Group in Verona.

"I manage the most high-risk population in the practice," she said, those with chronic conditions like diabetes and heart disease. "I reach out to patients who have had a hospital discharge or an emergency room visit, to make sure that they are at home, that they are settled, that their medications are correct. If they need a follow-up appointment with a doctor, I make it."

Duni, with 30 years experience as a nurse, including in the emergency room and intensive care, began the new 12-week training course in January, a combination of online and face-to face-instruction that focuses on case management using databases, skills Duni will use for the care she coordinates for 5,000 Vanguard patients who are Horizon members.

The training is funded by HHI, a new company launched in 2010 by Horizon Blue Cross and Blue Shield of New Jersey. "We are creating a new nursing leadership role that will support New Jersey's primary care doctors and deliver improved care to patients," said Christy Bell, chief executive of HHI.

Dr. Richard Popiel, president of HHI, said the company has been funding the hiring of population care coordinators since launching a patient-centered medical home pilot program more than a year ago with eight primary-care practices. That pilot was expanded with an additional 15 practices in January, and now involves about 80,000 patients. The curriculum to train more coordinators grew out of the work that has already begun in the medical practices.

"This gives us a great opportunity to formalize the education around what they are going to be doing in these practices," Popiel said. "This is something nurses have not been taught in traditional nursing schools."

At a press conference Wednesday at the Rutgers School of Nursing in Newark, Popiel said HHI is investing more than $1 million to train 200 nurses over the next two years. The nurses will work in medical practices that are partnering with HHI, which is both paying the cost of training the nurses, and providing additional payments to the medical practices so they can afford to hire the nurses.

At the Vanguard Medical Group, Duni said she spends a lot of time on patient engagement. "I try to make sure that patients understand that they are part of their own healthcare team and they are engaged in keeping themselves healthy."

Vanguard is a patient-centered medical home, having achieved that national certification for the quality of the patient-focused care it delivers. And because Vanguard uses electronic medical records, Duni can go into the database and find patients who are overdue for a colonoscopy or who have not had a routine examine in more than a year and then get in touch with them. She also makes referrals, for example to (behavioral health) therapists, physical therapy, or a visiting nurse.

Duni is seeing a positive impact of her work with patients over the past year. "They are much more engaged in what is happening with them," she said. "They understand that they are part of their own best health."

The outreach to the patients differentiates the program. "We contact people through letters, phone calls, emails, to get them into the practice to find out what their health report card looks like, and how they can participate," Duni said. Certain medical procedures have been found effective, such as routine blood work, blood pressure screening, and mammograms.

For the past year, Duni has been mining the database and getting to know the patients. She has identified hundreds of gaps in care when procedures are skipped and part of her mission is to close those gaps. Some patients are resistant to getting regular preventive medical care, she said, "and you have to change the culture and engage the patients into thinking that things aren't happening to them but they are choosing to do this, because they want to be as healthy as possible."

HHI decided to start with an eight-practice pilot "to make sure we got all the components right," Popiel said. Over the past year, the effort has yielded a 200-page manual called "the playbook," which addresses specific issues like how to manage hospitals admissions and drug spending.

The medical practices "actually helped build and design the processes and practices and make design changes," he said. For example, in order for population health to improve, the practices have to see patients regularly and the playbook addresses how to revamp scheduling to make sure these patients can get in to see the doctor. HHI has now developed the knowledge to begin scaling up the number of practices and patients.

Some costs are rising in the short run, Popiel said. Pharmaceutical costs are increasing because -- in the past -- patients were not taking their medications and now compliance has improved. But going forward, "totals costs should go down and make healthcare more affordable," he said. "It will be better for doctors who see revenue flowing to their practices. And it's better for us [Horizon] because we will have a more effective, efficient healthcare system."

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