One of the latest buzz phrases in healthcare is population health management. But it’s more than a passing trend. Patients and healthcare systems benefit when outpatient areas follow a model of care that is dedicated to maintaining and improving community health through wellness and prevention.

In 2017, Cleveland Clinic opened a population health unit, known as Cleveland Clinic Care Community. Earlier this year, ConsultQD featured an article on the unit and its first Senior Director of Nursing, Ruthann Gavrilescu, MSN, MEd, BSN. The unit encompasses adult primary care, pediatric primary care, express clinic care and at-home medical care across Cleveland Clinic’s 18 full-service family health centers, 10 regional hospitals and seven nurse-led chronic care clinics.

Among the caregivers who are integral in the operation of Cleveland Clinic Care Community are 50 primary care coordinators embedded in primary care practices. “As our patients become more and more complex, our healthcare system is also getting more and more complex,” says Kristine Adams, MSN, CNP, ACNO of Care Management and Ambulatory Services. “It’s getting more difficult to navigate the healthcare system, and patients are getting overwhelmed. Care coordination is there to support and pad that patient with the resources they need to make things as easy as possible for them.”

Decreasing patient utilization

Primary care coordinators at Cleveland Clinic, who are all registered nurses, work hand in hand with high-risk patients identified by an internal algorithm that considers patient demographics, disease states, utilization and claims data. “Their primary role is to decrease patient utilization, and they do that in a few ways,” says Adams.

• Closing gaps in care associated with a specific disease. Care coordinators help ensure that patients do everything necessary to keep diseases or chronic conditions in check. For instance, if a patient has diabetes the care coordinator will help them set up an annual diabetic eye exam to prevent blindness, an annual diabetic foot exam to avoid non-healing wounds and an A1C test every four months to check kidney function. “We know through research and longitudinal management of these diseases that if patients do things to maintain their overall health, they do better in the long run and have a lower cost of care,” says Adams.
• Linking patients to community resources. Patients may need more services beyond day-to-day management of a chronic condition. Care coordinators provide access to behavioral health services, social work services, Meals on Wheels®, exercise programs and other resources. “These are all things that may help patients to be successful at staying out of the hospital and remaining home and independent longer,” says Adams.
• Coordinating routine healthcare maintenance. Care coordinators help their patients schedule mammograms, colonoscopies, immunizations, eye exams and other routine screenings. They also encourage patients to participate in weight loss programs, smoking cessation programs and other programs that can enhance health. “Care coordinators are cheerleaders and coaches,” says Adams. “They optimize patients to their highest level of wellness.”

Helping patients manage their own care

Cleveland Clinic’s care coordinators have been very successful in helping patients. Just recently, one RN shared her work with a diabetic patient. The care coordinator taught the patient to properly record blood sugar levels, connected the patient with a dietitian to improve her eating habits and linked the patient with a diabetic educator to better understand her medications. The patient’s diabetes is now under control for the first time in years.

That patient can now manage her condition on her own – the ultimate goal of care coordinators. “Once patients go on our rolls, we try to work with them for about 60 days,” says Adams. “By 90 days, we want them to graduate.” Part of the reason is capacity: New high-risk patients are always coming into the system. But another reason is that patients should learn to manage their own care. “We try to help people help themselves,” Adams explains.

Care coordinators in the Cleveland Clinic Care Community work in tandem with clinical nurses, medical assistants and physicians. “Care coordinators are one piece of a whole team that helps move the patient forward and get them where they need to go,” says Adams.

Primary Care Coordination Utilization Reduction

Cleveland Clinic followed 4,199 patients cared for by primary care coordinators in its Cleveland Clinic Care Community in 2017. Statistics reflect the success of care coordinators, whose main role is to reduce patient utilization:

• A 13 percent decrease in utilization of the Emergency Department in care coordinated patients.
• A 10 percent decrease in observation status in care coordinated patients.
• A 14 percent decrease in inpatient stays in care coordinated patients.
• A 47 percent decrease in the hospital readmission rate in care coordinated patients.