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Population care coordinators to improve care for New Jersey residents

From left, are Mary Wachter, RN, chief strategy officer, VNA Health and Hospice; and patient care coordinators Theresa Klein, RN, VNA Health Group; Janet Duni, RN, Vanguard Medical Group; and Claudia Casas, RN, Forest Hill Family Health Associates.

On Feb. 1, Rutgers University School of Nursing in Newark, N.J.; Duke University School of Nursing in Durham, N.C., and Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, announced the launch of a nursing collaborative to train nurses as population care coordinators in New Jersey. During the next two years, at least 200 nurses will receive education as PCCs to work in a patient-centered medical home program and other population-based health programs.

“The PCCs will serve as pioneers in implementing this new model in the state. Through this unique partnership, we are looking to shift care delivery from an illness model to one of keeping our citizens healthy,” said Edna Cadmus, RN, PhD, NEA-BC, clinical professor and director of the DNP program-leadership track at Rutgers. “The PCCs will serve as linchpins to analyzing data on high-risk patients and developing coordinated plans of care.”

PCCs assess the needs of high-risk patients and close the gaps in their care. Working with primary providers in the medical groups, they follow up on preventive and wellness strategies and arrange appropriate consultations.

“As a PCC, I connected a patient with Alcoholics Anonymous and expedited another patient, who was in acute distress, to receive preadmission testing and cardiac clearance prior to surgery,” said Janet Duni, RN, MPA, PCC in the Vanguard Medical Group in Verona, N.J. “Upon reviewing one patient’s medications, I discovered that he was double-dosing, and we discarded 18 expired medication bottles. After updating his medication list, I enrolled him in an automatic three-month reorder medication service through the Veterans Administration.”

Institutional collaboration

With Mary Aikins, RN, manager of care management operations at Horizon Healthcare Innovations, seated, left, are population care coordinators in training, from left, standing, Sonel Patel, RN; Theresa Klein, RN; Claudia Casas, RN; Deborah Hartigan Franco, RN; and Angela Lane, RN. Seated, from left, are Aikins; Carol Gaudet, RN; Maryanne McCormick, RN; and Lydia Stephen Remy, RN.

Offered through Duke, the 12-week course started last month with 37 nurses enrolled in the program. The training program focuses on population management and care coordination, case study scenarios, change, operations of a PCMH program and the role of PCCs. It consists of an online format and three face-to-face sessions, one held at Duke and two at Rutgers.

“We believe this is the first curriculum of its kind designed in partnership between academic institutions and a payer,” said Catherine L. Gilliss, RN, DNSc, FAAN, dean, Duke University School of Nursing. “We want to promote delivery of effective, accessible care that will decrease costs and improve patient outcomes.”

Rutgers will provide faculty support to students as they transfer theory to practice and transition into their new roles in the patient-centered medical home programs. At the on-site Rutgers workshops, students will use data management tools from Horizon. Panel presentations will include Project Dulce for diabetic patients and the Expecting Success program for cardiac patients. Online content at Rutgers focuses on leadership, role transition and transitional care models population data for New Jersey. Students will earn nine graduate credits through Duke.

As healthcare advocates, Janet Duni, RN, PCC in the Vanguard Medical Group, left, and Mary Aikins, RN, manager of care management operations at Horizon Healthcare Innovations, identify patients at high risk, assess their needs and close the gaps in their care. Working with primary physicians in the medical group, they update plans of care and follow up on preventive and wellness strategies.

“Case managers from across the continuum will present case studies from their environments, and we will discuss how we can better collaborate to ensure smooth transitions,” Cadmus said.

“It is a challenging and exciting role in nursing where we cannot only prevent patients from having adverse events but also empower them to take charge of their own health,” Duni said.

By | 2020-04-15T09:44:39-04:00 February 20th, 2012|Categories: New York/New Jersey Metro, Regional|0 Comments

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