Thursday, May 21, 2009

The Biggest Secret About the New Disease Management: Externally Supported & Shared Nurses for the Medical Home

At the Chronic Care & Prevention Congress, the Disease Management Care Blog heard about Pennsylvania’s chronic care initiative, North Carolina’s Community Care, the 1115 Waiver in Los Angeles County and Health Dialog’s involvement and support for care management programs. All involved a ‘medical home’ approach to chronic illness and all shared a key ingredient: the nurse coaches were not hired, underwritten, salaried, supported or owned by the primary care sites. Instead, all were bankrolled, controlled, managed or employed by an external third party. That third party was often a public or commercial insurer, a not-for-profit agency, grantee or disease management organization. By the way, the same is functionally true in integrated delivery systems' medical homes, where a cost center other than the primary care network typically bears the cost of the training and staffing the care management nurses.

What's more, the nurses described at the Congress were not the typical remote telephonic coaches that characterized past 'Ver. 1.0' disease management programs. Instead, these nurses were ‘boots on the ground,’ hands-on nurse coaches that were ‘embedded’ in the primary care sites.

To the DMCB, this represents the biggest secret about modern versions of disease management. 'Head-set' enabled nurses occupying a floor in some generic building across State lines still have a role to play in population-base care management, but that is so... 'been there, done that.' We're now witnessing the integration of the same highly trained non-physician professionals in the primary care sites. They're giving the local community physicians a leg-up in attaining status as a team-based medical home.

This turn of events has been conspicuously absent in the healthcare media and medical literature and has been largely ignored by policy makers - at least in public. For smaller primary care sites struggling on shoe-string budgets, the gratis provision of a ‘plug and play’ nurse is a no brainer. What’s more, the nurse support can be ‘flexed’ on a day-to-day basis, depending not only on the daily number of patients with chronic illness but the needs of other clinics – which can share the nurse. In other words, circuit-riding disease management/medical home ‘blended’ nurses can support multiple PCPs, resulting in far greater efficiency.

The DMCB realizes that purists may tut-tut over the notion of a generic nurse being diluted among multiple sites. While this runs counter to the notion that each site is a 'home' unto itself, the DMCB suspects shared nurses are more likely to support a single standard of care, leading to reduced variation. While there is no research (yet) that has shown that the shared nurses are really better, relying on them in the settings described above is early compelling evidence that this approach can work.

The DMCB asked an expert panel at the Congress to comment on the prospect of disease management organizations or other types of 3rd parties supplying the nurses. They agreed with the idea: so long as the primary care physician is closely integrated and ultimately responsible, it shouldn't make any difference.

What does this mean? The DMCB suspects adoption of the medical home by primary care sites in any given network will be spotty. In sites that have the resources and are able to build a medical home from the ground up, that'll be fine. However, other sites may be unable to commit to a fully functional home. In that instance, the nurse circuit riders will come to their - and their patients' - rescue.

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