SummarySupported by sophisticated information technology and a separate outreach team, cross-trained nurse practitioners employed by a Medicare Advantage plan run disease-specific clinics in which they work with a defined group of patients to educate them about self-management and proactively manage and coordinate care related to diabetes, wounds, congestive heart failure, hypertension, pulmonary disease, and coronary artery disease. Employed by the health plan, the nurse practitioners operate out of 20 care centers located throughout the service area. An individual patient may receive support for more than one of these conditions/diseases during a single visit with a nurse practitioner. The program has significantly improved outcomes across targeted diseases/conditions, with reductions in the following: blood pressure for hypertensive members, blood glucose levels for diabetic members, readmission rates for congestive heart failure patients, and amputation rates for diabetics suffering from vascular and other types of wounds.Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure, blood glucose levels, and CHF readmissions in members treated in the nurse practitioner–led clinics, along with a comparison of CareMore's lower-limb amputation rate among members with diabetes to an estimate of the national average among Medicare beneficiaries.
Date First Implemented1995
The nurse practitioner–led clinics began in 1995 with the diabetes program.
Patient PopulationThe program serves seniors with diabetes, CHF, hypertension, wounds, pulmonary disease, and CAD.Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Medically or socially complex; Insurance Status > Medicare; Age > Senior adult (65-79 years)
Problem AddressedSeniors with chronic conditions and diseases, including diabetes and diabetes-related wounds, congestive heart failure (CHF), hypertension, and coronary artery disease (CAD), often face challenges in managing their condition on an ongoing basis, leading to increased risk of costly, debilitating acute episodes. Proactive, ongoing monitoring, management, and self-management support can help to reduce the risk of an exacerbation, but many seniors lack access to such services on an ongoing basis.
- Many elderly with multiple, costly chronic conditions: Roughly two in three seniors (65 percent) suffer from two or more chronic conditions (e.g., diabetes, CHF, hypertension, asthma), and these individuals account for 95 percent of Medicare costs.1
- Failure to provide proactive management and support: National guidelines have been established to help providers manage and treat chronic conditions, but only about half of patients with these conditions receive adequate management based on these guidelines. In addition, providing chronically ill individuals with education, information, skills, and motivation to manage their conditions, and monitoring their ongoing progress in doing so, can also yield significant benefits.1 But relatively few seniors receive such support, particularly those in the Medicare fee-for-service system, where financial incentives tend to discourage the provision of services designed to prevent admissions and acute episodes.
- Leading to cycle of acute episodes and readmissions: Many seniors with chronic conditions face a cycle of acute episodes that repeatedly lead to the need for emergency department (ED) and/or inpatient care. For example, almost one-third of hospitalized CHF patients are readmitted within 30 days of discharge.2 Readmission rates are also high among Medicare beneficiaries with other chronic conditions, with roughly one in five hospitalized Medicare fee-for-service beneficiaries being readmitted within 30 days and more than one in three being readmitted within 90 days.3 These readmissions often occur due to inadequate self-management and lack of ongoing monitoring and followup after discharge.4
Description of the Innovative ActivitySupported by sophisticated information technology (IT) and outreach support, a team of cross-trained nurse practitioners employed by a Medicare Advantage plan run disease-specific "clinics" in which they work with a defined group of patients to educate them about self-management and proactively manage and coordinate care related to diabetes, wounds, CHF, hypertension, pulmonary disease, and CAD. An individual patient may receive support for more than one of these conditions/diseases during a single visit with one practitioner. Key elements of the program are described below:
- Referring patients to clinics: CareMore members come to the program from a variety of sources, including internal analysis of claims and other data that identifies those members with one or more of the targeted conditions, and referrals from primary care physicians (PCPs) and physician "extensivists" (see the associated profile on the role of the CareMore medical extensivists). In addition, CareMore's preauthorization process reviews any PCP request to send a member to a specialist (e.g., a referral of a member with diabetes to an endocrinologist); as clinically appropriate, CareMore will intervene and send the member to the nurse practitioner–led clinic first. (The nurse practitioner can later refer the member to the specialist if necessary.)
- Disease-specific, nurse practitioner–led clinics: Most CareMore care centers have one or more full-time trained nurse practitioners who teach self-management skills and manage and coordinate care for a defined group of members with one or more of the following: diabetes, diabetes-related and other wounds, CHF, hypertension, pulmonary disease, and CAD. (See the Planning and Development section for more information on training.) With support provided to the nurse practitioners as needed from specialist physicians in each field, an individual patient with two or more of these conditions can receive condition-specific care from the same nurse practitioner during a single visit. As necessary, nurse practitioners will refer patients to other CareMore support programs that can help them in managing their disease/conditions, such as a "home" team that can analyze and address risks in the home environment and a social "SWAT" team that can connect members to needed social and other support services. Additional details on how the nurse practitioner–led clinic addresses specific diseases/conditions follow:
- Diabetes clinic: Approximately 30 percent of CareMore members have diabetes. Nurse practitioners regularly see these individuals to monitor their condition, making sure they stay up to date on needed examinations (e.g., foot and eye examinations) and educating them on appropriate self-management strategies, including diet, physical activity, and medication adherence. They also teach them to recognize and respond to any warning signs of an impending acute episode. The nurse practitioners are supported in their work by data transmitted from a home glucometer given to all diabetic members, and by a separate team of four full-time nurse practitioners who conduct outreach. (See bullets below for more information on the outreach team and data transmission.)
- Wound care clinic: Nurse practitioners proactively manage vascular and other wounds (often diabetes-related) that seniors may have. Such wounds generally require frequent (sometimes daily) visits to ensure proper healing and prevent dangerous infections. The nurse practitioners focus on treating the wound as quickly and comprehensively as possible to prevent a worsening of the condition and the need for referral to a vascular surgeon, as surgery to bypass damaged arteries/vessels (a common treatment for severe wounds) can often lead to additional complications, sometimes resulting in the need for amputation.
- CHF clinic: With support from a cardiologist and a biometric telemetry program that allows for proactive monitoring of patients in the home (see bullet below), nurse practitioners regularly see CHF patients to check their weight, make sure they remain compliant with their medications, and assist in self-management and in recognizing and responding to warning signs of an acute episode. Anyone at risk of an acute episode can, as necessary, be sent to a cardiologist who oversees the program.
- Hypertension clinic: Supported by inhome monitors (see bullet below), nurse practitioners regularly treat patients with hypertension, reviewing electronically transmitted data with patients to help ensure that blood pressure remains under control. As necessary based on the data, the nurse practitioner can work with the senior to improve medication compliance and lifestyle-related behaviors (e.g., salt intake), and can change or adjust medications.
- Electronic and outreach support: CareMore's IT systems, including an electronic medical record (EMR), support the nurse practitioners as they see patients, as do a separate group of four nurse practitioners who monitor incoming data and proactively reach out to patients with CHF and hypertension who require inhome monitoring.
- Embedded templates to guide visit: Through CareMore's EMR, nurse practitioners have access to disease- and condition-specific templates based on established guidelines and protocols related to self-management education and ongoing management and treatment. These templates serve as a guide for the nurse practitioners during visits. For a patient suffering from more than one disease/condition, the nurse practitioner can call up multiple templates during the visit, typically working through each in succession to make sure that all issues can be adequately addressed.
- Access to home-monitoring data: For select CHF, hypertensive, and diabetic members, clinic nurse practitioners have access to additional data provided by inhome monitoring and biometric telemetry devices; members can be referred to this program from any "touchpoint" in the CareMore delivery system. Members with diabetes receive a home glucometer used to periodically measure blood glucose levels, which are automatically stored in the device and can be downloaded by diabetes clinic staff to assist them in working with patients. Members with high blood pressure receive an inhome biometric telemetry device that regularly measures blood pressure and transmits values over the Internet. CHF patients have a similar device to monitor weight. These systems tie into an Internet-based interface, which has built-in applications that provide real-time alerts and decision support to nurse practitioners and other clinicians based on incoming data.
- Outreach team and call center: A team of nurse practitioners and medical assistants regularly reviews data and alerts from the CHF and hypertension monitoring devices, making outbound phone calls as needed to deal with potential exacerbations and to encourage members who may be at risk to come to the nurse practitioner–led clinics. A separate call center reaches out to at-risk members, such as those with diabetes who register two consecutive hemoglobin A1c tests over 8 percent.
- Regular communication with PCP: Nurse practitioners have predefined "touchpoints" that guide when and how they interact with the member's PCP. For example, for those with diabetes, the nurse practitioner engages in systematic communication with the PCP when any of six defined events occur (e.g., admission to or discharge from the program, a medication change, failure to comply with medications, out-of-range blood glucose levels). Similar predefined touchpoints exist for those with CHF and hypertension and for those in need of wound care.
Contact the InnovatorHenry Do, MD
Senior Medical Officer
12900 Park Plaza Drive, Suite 150
Cerritos, CA 90703
Phone: (562) 207-3646
Innovator DisclosuresDr. Do has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program significantly improved outcomes across all targeted diseases/conditions, with reductions in the following: blood pressure for hypertensive members, blood glucose levels for diabetic members, readmission rates for CHF patients, and amputation rates for those suffering from vascular and other types of wounds.
Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure, blood glucose levels, and CHF readmissions in members treated in the nurse practitioner–led clinics, along with a comparison of CareMore's lower-limb amputation rate among members with diabetes to an estimate of the national average among Medicare beneficiaries.
- Better blood pressure control: In a longitudinal analysis of blood pressure in 237 patients treated in the clinic, average systolic blood pressure fell by 10 mm Hg (from 145 to 135 mm Hg). Two-thirds of patients experienced a drop of at least 5 mm Hg, while nearly half (48 percent) experienced a drop of at least 10 mm Hg. Those with the highest blood pressure at enrollment in the nurse practitioner–led clinic experienced the greatest reductions.
- Better blood glucose control: Among 224 members who visited the nurse practitioner at least twice over a 4-month period beginning January 1, 2008, 28 percent experienced a decline in blood glucose level over the subsequent 6 months, including 21 percent with a drop of more than 0.5 points and 7 percent with a drop of more than 2 points. In contrast, only 21 percent of these members experienced an increase in blood glucose levels, and only 12 percent had an increase of more than 0.5 points and 2 percent had an increase of more than 2 points. Subsequent analysis determined that many members who experienced an increase in blood glucose levels had normal levels at the beginning of the measurement period, and hence should have been discharged from the clinic earlier. (CareMore subsequently improved its discharge process accordingly.)
- Fewer CHF readmissions: In a longitudinal analysis of 270 CHF patients treated at the clinic, inpatient admissions fell by 56 percent, from 39 during the 3-month period before enrollment in the clinic to 17 admissions among the same group of members during the 3 months after enrollment. (Admissions during the month of enrollment have been excluded from this analysis.)
- Much-lower-than-expected amputation rate: An analysis of 7,450 members with diabetes found that CareMore has an annual lower-limb amputation rate of 2.1 per 1,000 members with diabetes, with 16 individuals experiencing one or more lower-limb amputations between July 1, 2007 and June 30, 2008. This figure is 76 percent below the 9.8 lower-limb amputations per 1,000 found in a large study of Medicare beneficiaries with diabetes.5 Although this low rate of amputations cannot be attributed solely to the nurse practitioner–led wound and diabetes clinics, program developers believe that the proactive management provided by this program has helped to avoid the need for many amputations.
Context of the InnovationCareMore operates network-model Medicare Advantage plans and special needs plans for seniors in Southern California (High Desert, Los Angeles, and Orange County), Northern California (Modesto), Arizona (Tucson), and Nevada (Las Vegas). CareMore serves 44,000 members, with membership having grown by 30 percent in the last year. CareMore began as a single staff-model medical group, which later expanded to include a variety of medical groups, individual physician practices, independent practice associations, and physician pods that contract with the CareMore plans. To participate in CareMore plans, network physicians must agree to collaborate with CareMore in the use of its many programs, including 20 CareMore outpatient centers, to manage care of the frail elderly, which represent a significant portion of the membership. The nurse practitioner–led clinic program developed after one nurse practitioner with expertise in diabetes and wound care began seeing members with diabetes on a regular basis in one CareMore center. Over time, CareMore leaders began to recognize the potential of nurse practitioners with expertise in specific chronic diseases/conditions to improve outcomes and reduce costs, and decided to grow the program by training other nurse practitioners to perform this role and by expanding the program to serve those with other chronic diseases and conditions.
Planning and Development Process
Key steps in the planning and development process included the following:
- Initial implementation with one nurse practitioner: As noted, the program began relatively informally with one nurse practitioner who had expertise in diabetes and wound care. At this point, the nurse practitioner had few formal systems to support her in this work.
- Formalizing and systematizing program over time: Over time, CareMore leaders began to formalize the program, creating systems to support the nurse practitioners in their work and to ensure a steady flow of referrals into the program. This process included the following steps:
- Defining and updating protocols: CareMore clinicians with expertise in the relevant diseases/conditions reviewed relevant guidelines and protocols, and then adapted and customized them to the standards of the local community. On an ongoing basis, clinicians review and update these protocols as necessary.
- Integrating into EMR templates: CareMore IT staff worked to integrate these protocols into EMR-based templates that nurse practitioners could use while working with patients. As the protocols are updated, IT staff update the corresponding templates to reflect the changes.
- Training nurse practitioners: Over time, CareMore created a relatively formal 3-month training process to teach nurse practitioners the relevant skills and knowledge needed to care for patients with each of the targeted diseases/conditions. This process included teaching them about the protocols and templates, and having them conduct "rounds" with the various other CareMore programs that can support these patients, including the aforementioned home and social SWAT teams. During the training period, new staff initially shadow more experienced nurse practitioners; over time, the new nurse practitioners take over patient care responsibilities, with a more senior nurse practitioner overseeing them until they became comfortable seeing patients on their own.
- Defining touchpoints with PCPs: For each condition, nurse practitioners worked with PCPs to jointly develop a list of events or situations that trigger the need for systematic communication, such as admission or discharge from the clinic.
- Educating PCPs and other referral sources: Through various mechanisms, CareMore educated PCPs and other clinicians about the nurse practitioner–led clinics and their potential to support them in caring for patients with chronic diseases/conditions. These education efforts continue on an ongoing basis.
Resources Used and Skills Needed
- Staffing: CareMore has approximately 20 full-time nurse practitioners who lead disease- and condition-specific clinics across its 20 care centers. Most, though not all, care centers have at least one full-time nurse practitioner, with some larger centers having two or three. Although caseloads vary across conditions, the typical nurse practitioner takes responsibility for roughly 1,500 members.
- Costs: Data on program costs are unavailable, but they consist primarily of compensation for the nurse practitioners. CareMore leaders have not explicitly analyzed the return on the plan's investment in this program, but they believe it more than pays for itself through reductions in costly acute episodes, including CHF readmissions and amputations.
The program is funded internally by CareMore.
Getting Started with This Innovation
- Start small and grow over time: Begin with one nurse practitioner focused on one disease state or condition, and then expand the program over time based on lessons learned from this initial experiment.
- Customize to local practice: Although national guidelines and protocols exist on how to care for many chronic diseases, they must be adapted and customized to accepted practices within a community. For example, if endocrinologists typically oversee the care of those with diabetes, have an endocrinologist available to support the nurse practitioners in the diabetes clinic.
- Involve physicians in design and development: Work with PCPs and relevant specialists on the design and development of the clinics, as these physicians must be willing to support and refer appropriate patients to the nurse practitioners.
- Use systems to identify those who could benefit: CareMore's IT systems allow it to identify members who can benefit from the nurse practitioner–led clinics. These patients can then be contacted to gauge their desire to receive clinic services; those interested can be enrolled in the program and assigned to a nurse practitioner's caseload.
Sustaining This Innovation
- Regularly remind potential referral sources about program: The clinics rely on PCPs and other physicians for ongoing referrals of patients. To maintain clinic volumes, regularly remind employed and network physicians about the program and its potential benefits.
- Adhere to established "touchpoints": Physicians will not continue to support the program unless they are kept informed about important changes in a patient's condition. To maintain their enthusiasm and support, rigorously adhere to the established triggers for initiating contact with PCPs and other clinicians.
1 Health Insight. Moving towards transformational care. QualityInsight. Fall 2006.
2 Landro L. Keeping patients from landing back in the hospital. The Wall Street Journal. December 12, 2007. Available at: http://online.wsj.com/article/SB119741713239122065.html.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. [PubMed]
4 Transforming care at the bedside how-to guide: creating an ideal transition home for patients with heart failure. The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation; October 2007.
Bertoni AG, Krop JS, Anderson GF, et al. Diabetes-related morbidity and mortality in a national sample of U.S. elders. Diabetes Care 2002;25:471-75. [PubMed]
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Service Delivery Innovation Profile
Original publication: October 13, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.