DOI: 10.1097/NHH.0000000000000130
,
,
PMID: 25171247
Issn Print: 0884-741X
Publication Date: 2014/09/01
Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
Recognizing the growing importance of population health management, Visiting Nurse Service of New York (VNSNY) has partnered with Duke University School of Nursing and New York University College of Nursing to advance population care management knowledge among our nursing staff and leadership. Nearly 100VNSNY nurses have participated in the semester-long Duke Population Care Coordinator (PCC) program, which teaches clinicians to identify emerging trends in patient populations, giving them tools to help patients manage chronic and complex health issues and improve patient outcomes by helping interprofessional teams interact more efficiently and effectively with the patient, thereby avoiding unnecessary emergency department visits and hospital readmissions.
As developed at Duke University School of Nursing, PCCs arenurses trained to help create and implement population risk-stratification and patient-centered approaches to care, enabling groups and individuals to access high-quality, comprehensive care within the context of their community. PCCs work with patients and interprofessional teams to create individual plans of care, and look at subpopulations and identify high-risk conditions for which outcomes could be improved, using a disease registry design. At VNSNY, clinicians in frontline and leadership positions are applying this competency to manage care of individual patients, identify population cohorts within the health system, and advance the health of broader communities. They are managing beneficiary populations in our own health plan and other health plans, and participating in accountable care organizations and independent practice associations as integrators between the primary care setting and the broader healthcare delivery system, as transition stewards through partnership roles within inpatient units and on steering committees of large, multisite health systems, and as members of crosscontinuum interprofessional teams with health insurance partners.
Through population care coordination, nurses are fulfilling the promise of the IOM Report on the Future of Nursing, acting as architects and coleaders in transforming the healthcare system. Within health plans, PCCs are using predictive analytics to coordinate care for vulnerable populations. As transition liaisons within hospitals, PCCs are developing innovative care models, analyzing inpatient data to identify patient characteristics, intervention modalities, and care setting—all with the goal of protocolizing plans of care from primary care or specialty practice through postacute episode to effect top-decile performance on outcome measures and patient experience.
This approach's effectiveness is underscored by results at a major medical center's postoperative cardiothoracic unit, where a population-based approach achieved reduced lengths of stay, avoidance of postdischarge to a subacute facility, a statistically significant drop in first 30-day all-cause readmissions, and performance superior to regional and national benchmarks on publicly reported outcomes. On another unit, the PCC reduced length of stay by 5 days for inpatients receiving anticoagulation therapy.
These competencies are embedded in VNSNY's bundled payment models, with nursing leaders applying an epidemiological view to patient care, integrating predictive analytics, risk acuity, and “dosed” interventions for beneficiaries. Our early results in a Model 2 demonstration reveal reduced rehospitalization rates and safe shifting ofpostoperative care to the home in lieu of skilled nursing facilities. Preliminary results ina Model 3 demonstration, integrating telehealth, patient engagement, and health coaching, also show reduced rehospitalization rates.
