When Sentara Medical Group determined its RN case managers working inside physician practices spent just a quarter of their time on managing care, it decided to rewrite its approach to embedded case management.

In the retooled and highly effective version, Sentara's RN case managers now meet patients where they are—at home, in the hospital, in the primary care provider office, on the phone or online via Skype or FaceTime virtual sessions—an approach that has reduced overall cost of care by 17 percent for SMG's highest risk, highest cost patients.

Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination documents Sentara's successful hybrid approach to case management that has improved outcomes for both patients and physician practices.

In this 25-page resource, Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group, details the care management overhaul that has dramatically reduced ER utilization, hospital admissions and readmissions among high-risk 'VIPs.' Ms. Morin provides the following details:

• The 10 goals of Sentara's ambitious care management program that includes advance care planning and a strict seven-day follow-up metric;
• Its seven-pronged population health management model;
• Composition and responsibilities of the care team, which includes providers, RN care managers, PharmDs and newly added social workers;
• Nuts and bolts of the SMG RN Care Management model, including patient assignments, core competencies, work flows, communication, education and training, and more;
• Addressing the behavioral and community health needs of vulnerable, high-risk VIPs;
• The challenges of engaging providers, staff and patients in this bold new case management approach;
• The nine key roles of the RN case manager, including care plan development, care transition management and advance care planning;
• SMG care management outcomes, including metrics on hospital admissions, readmissions, ED utilization and seven-day follow-up;
• Lessons learned from program development and roll-out;

Table of Contents

• A Hybrid Embedded Case Management Model: Sentara Medical Group’s Approach
  • Converting to a Hybrid Case Management Model
  • Program Focus
  • Challenges of Targeted Populations
  • Population Health Management Across the Continuum
  • Composition of the Care Management Team
  • Rewriting the RN Care Manager Job Description
  • RN Care Manager Core Competencies
  • Overcoming Patient and Provider Pushback
  • Outcomes from RN Care Management
• Q&A: Ask the Expert
  • Supporting Hybrid Case Management through System Leadership
  • Using Social Workers for Community or Behavioral Health
  • MD-to-RN Referral Criteria
  • RN Care Management Case Loads
  • Using the EPIC EMR
  • Support Team for Case Management
  • Certifications and Accreditations
  • ‘First Call’ Protocols
  • Provider Site Metrics and Staffing
  • Criteria for Program Discharge
  • RN Case Manager Duties
  • Home Visit Protocols
  • Program Productivity Metrics
  • Plan of Care Ownership
  • ‘Labeling’ Patients on a Panel
  • Disease Guidelines and Protocols
  • Distinguishing Inpatient Care Coordination from Case Management
• Glossary
• For More Information
• About the Presenter