A project initiated to serve seniors has twenty full time cross-trained nurse practitioners employed by a Medicare Advantage plan called CareMore running twenty disease-specific clinics supported by high technology.
Using technology helps the nurse practitioners work with the patients to educate them on how to self-manage and coordinate their care as it relates to diabetes, wounds, CHF, hypertension, pulmonary disease, and CAD. Although caseloads vary across conditions, the typical nurse practitioner takes responsibility for roughly 1,500 patients.
CareMore operates network-model Medicare Advantage plans for seniors in Northern and Southern California, Arizona, and Nevada. The nurse-practitioner-led clinic program developed after one nurse practitioner with expertise in diabetes and wound care began seeing seniors with diabetes on a regular basis in one CareMore center.
CareMore’s IT systems include EMRs that support the nurse practitioners as they see patients, while other groups of four nurse practitioners monitor incoming data and then are able proactively to reach out to patients with CHF and hypertension if they require in-home monitoring.
For select CHF, hypertensive, and diabetics members, nurse practitioners have access to additional data provided by in-home monitoring and biometric telemetry devices. Members with diabetes receive a home glucometer to periodically measure blood glucose levels that are automatically stored in the device and can be downloaded by diabetes clinic staff to help monitor the patient.
Members with high blood pressure regularly use biometric telemetry devices to measure blood pressure and then transmit this information over the internet. CHF patients have a similar device to monitor weight. All of these systems tie into an internet-based interface which has built-in applications to provide real-time alerts and decision support to nurse practitioners and other clinicians.
A team of nurse practitioners and medical assistants regularly review the data and the alerts from the CHF and hypertension monitoring devices. If necessary, phone calls are made 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 with diabetes who register two consecutive hemoglobin A1C tests over eight percent.
To further help guide visits, nurse practitioners through CareMore’s EMR system have access to disease and condition-specific templates based on established guidelines and protocols related to self-management, education, and treatment. For a patient suffering from more than one disease/condition, the nurse practitioner can call up multiple templates during the visit so that all health issues can be addressed. As protocols are updated, IT staff updates the corresponding templates.
The results in the program show significantly improved outcomes and reductions in blood pressure, lower blood glucose levels, lower readmission rates for CHF patients, and lower amputation rates for those suffering from vascular and other types of wounds.