Form & Function of
Coordinated Care
Bonnie Briggs, RN, BSN, CCM and Scott Weltz, FSA
Coordinated Care Foundations
Coordinated care is a nursing service that proactively helps manage health plan
resources. Best practices include:
- Benefits are coordinated using a single nursing record that integrates all absence,
case, condition (disease) and utilization management information;
- Case identification system for Case and Condition Management is employed, integrated
into to the nursing record and is a validated prospective health risk scoring system
based on medical and pharmacy claims;
- All processes, communications and reports are HIPAA compliant and URAC accredited;
- On request, treating physicians can have a “peer to peer” discussion
with a medical director/advisor; for non-certification of services and
- First level review appeals go directly to a specialist physician.
Using these practices as a foundation, a simple way of understanding how care is
coordinated is to look at a Disease Cost Curve for an individual with Congestive
Heart Failure.
An Example Patient
Stage I
- Increasing Prescriptions, Diagnostics & Services
- Rapidly Increasing Health Risk
- Work absences increasing
Stage II
- Involves intense service (inpatient stays, outpatient surgeries, etc.) to stabilize
patient
- May also include follow-up visits, rehabilitative services, therapy, etc.
Stage III
- Patients typically stabilize
- Back to work
- Lower costs, but higher than Stage I when chronic disease present
- Costs may spike periodically depending on patient’s self-care / doctor’s
involvement
How Conduent Care and Quality Solutions’ Services Fit In
Stage I – Pre-Acute Care
- Absence Management Return to Work Evaluation & Management
- Continuous Risk Assessment
- Claims-based Predictive Modeling
- If patient has targeted condition, invite into Condition Management
- If significant increase in health risk, invite patient into Case Management
- Patient maintains contact with one nurse for continuity
Stage II – Acute Care
- Utilization Review
- Pre-certification of inpatient stays & other specified services (per plan)
- Concurrent & Retro review
- Case Management Care Plan
- Coordinate with physician, patient, family and plan
- Alternative, Home Health, Specialty Pharmacy Coordination
- Condition Management program continues
- Use Predictive Modeling / HRA to monitor for Stage I markers
Stage III – Post-Acute Care
- Use Predictive Modeling / HRA to monitor for Stage I markers
- Absence Management to return to work and review sick day triggers
- Condition Management continues to educate patient on key self nursing care behaviors
& prevention
- Utilization Review / Case Management helps manage future acute care “blips”
Coordinated Care Continuum
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Navigation, Help & Education
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Unscheduled Absence from Work
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Short-term Acute Illness
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Chronic Illness
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Complex & Catastrophic
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Service
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Advocacy
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Absence Management
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Utilization Review
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Condition Management
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Case Management
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Benefits
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Better plan risk management with defined appeals and problem resolution system
Eliminates, reduces and/or outsources employer staff work relative to handling plan
issues/problems
The majority of employees want help resolving billing, network and plan administrative
issues
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Manages unscheduled absences due to disability, workers’ compensation and
FMLA
Trigger Condition, Case and/or Utilization Management
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Prospective and concurrently reviews procedures and services based on generally
accepted criteria
Negotiates appropriate and cost-effective utilization of inpatient, outpatient and
professional services
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Continuously identifies and provides coordinated health and benefit management for
individuals with chronic health conditions
Promotes early intervention and compliance with treatment plan
Triggers utilization and case management services
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Continuously identifies and provides management services to catastrophic, transplant
and complex medical conditions
Identifies and coordinates care for the few that drive most of the health plan cost
Interfaces with reinsurance vendors and coordinates specialty pharmacy program needs
for the patient
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ROI Drivers
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Helps people become better consumers
Minimizes plan risk by having independent appeals
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Improves productivity while decreases health care costs and staffing coverage expenses
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Eliminates extended Length of Stay by referring to a more cost effective level of
care
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Prevention, early intervention and teaching decreases the long term cost of diseases
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Reduces episode of care costs
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