Are health plan nurses measurably ready for the future?

The innovations and opportunities resulting from healthcare reform—accountable care organizations (ACOs) and patient-centered medical homes—rapidly expand the roles of nurse care managers. These models require population-based analysis and prioritization, proactive care gap closure and care coordination, and credible assessment of impact to determine if cost and quality are improving.

At the core of all these models and the transformative direction of health reform, are key design principles that include:

• Population-based analysis used to target and prioritize interventions
• Accountability for achieving quality and financial goals for defined populations
• Patient-centered care design that addresses medical as well as psychosocial needs
• Education and engagement strategies that directly involve the patient and family in achieving better health and preventing exacerbation of chronic care
• Medical homes and medical “neighborhoods” that integrate primary care, specialty care, and community programs in a manner that provides better resource use and easier access
• Care coordination that assists patients as they maneuver the complexities of the healthcare delivery system
• Proactive outreach that encourages timely preventive care and supports care compliance
• Transparent discussions and thoughtful choices made based on evidence-based options and costs of alternatives

The clinical aspects and individual member focus of these models resonates with nurses but population-based measures of utilization, cost, risk scores, clinical prevalence, and incidence are foreign. Too often, when asked questions about this information, the answer is “the actuaries/analysts/finance people track that.”

This measurement gap can result in capable, clinically experienced professionals aiming well designed programs and processes at the wrong members. In the future, one overriding theme in care management, and health plan management in general, is the need for targeted programs and efficient management processes.

In our work with clients we are seeing an increasing number of care management units and management teams developing and using operational metrics to manage workloads and processes. This is a very positive development and these supervisors and managers are usually very knowledgeable about workload goals and performance and are able to tell you the statistics. But there continues to be limited discussion and knowledge about population clinical patterns (condition prevalence and incidence), resource patterns (utilization and cost), and risk patterns.

There is an opportunity to begin to involve the nurse care managers and the management team members (care management supervisors and managers) in learning about population-based statistics and calculations. Not everyone will find this fascinating but this should be a foundation for management team training. Many clients are exposing care management managers to the Healthcare Effectiveness Data and Information Set (HEDIS) and how it is calculated and that is a great foundation for learning even more about analytics. This is also an opportunity to get the nurse and care coordinators together with your analysts, actuaries, Master of Public Health (MPH)-trained staff, and medical directors (if they are responsible for measurement and analysis).

Many health organizations have routine brown bag or clinical rounds delivered both onsite and virtually. These sessions are designed to keep the care management teams up to date clinically and working as a team. Topics are the usual suspects—diabetes, complex cases, co-management opportunities. One idea is to use these sessions, or management team meetings, and add measurement to the annual agenda.

The organization can rotate in different sessions and topics as well as speakers from across the plan, hospital, or clinic. Topics, and speakers, could include:

• Population Resource Measurement 101 (Healthcare Economics)—inpatient and outpatient utilization and cost analysis, how to calculate per member per month (PMPM) costs and why
• Getting to Know You: Population Clinical Analysis (MPH)—incidence and prevalence, trend and what it tells us
• HEDIS, Agency for Healthcare Research and Quality (AHRQ), Prevention Quality Indicators (PQIs): The Science and Math Behind the Letters (Healthcare Economics)—how these organizations research and create measures, what is in the denominators and numerators
• Risk Scores and Care Management (Actuary, Healthcare Economics)—what are risk scores, what do they tell us and how can you use them
• Be Kind to Math Majors Day (Chief Actuary)—what is an actuary and what is that role
• Advanced Measurement 102 (Healthcare Economics)—benchmarking, variance analysis, heat maps

This article first appeared at Milliman MedInsight.

One thought on “Are health plan nurses measurably ready for the future?

  1. Totally agree with your ideas. The importance of the need for nurses and health care providers to be savvy about patterns in prevalence, incidence, resource utilization, quality indicators, reimburements – health care economics cannot be overemphasized. We need to start the basics at the undergraduate training of our health care providers. Awareness may increase the likelihood of “buy in” and “buy in” may lead to better collaboration among stakeholders = hopefully resulting in quality care in spite of controlled cost escalatiion.

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