Care Management
The Sequent Clinical Team is focused on building strong care teams, coordinating care across the continuum and leveraging information systems to ensure patients receive evidence-based care. The team is comprised of two distinct clinical roles: Registered Nurse (RN) Care Manager and Care Coordinator. Having two distinct roles allows each team member to work at the top of their license/skill set to ensure efficient use of care management/care coordination resources.
The Clinical Team
The RN Care Management focuses on developing personalized care plans for patients with multiple, uncontrolled chronic conditions and patients identified as high risk for admissions and/or readmissions to the hospital. Care planning focuses on engaging the patient as an active member of the care team to work towards patient - centered goals. In addition, the RN Care Manager focuses on transitional care outreach post-hospital discharge.
The Care Coordinator role is typically an individual with Medical Assistant experience and is focused on closing gaps in care across the entire patient population regardless of the patient's level of risk. This ensures patients are receiving education about evidence-based screenings. The Care Coordinator also assists the RN Care Manager in coordinating post-acute services, specialty referral and community-based services where appropriate.
The Sequent Clinical Team receives extensive training in population health and quality improvement processes. This ensures the team has a strong understanding of how to leverage the data systems available to measure and drive reductions in waste within the system and improve the quality of care for the patients served by Sequent providers.
Additionally, the Sequent Clinical Team focuses on forming partnerships with appropriate health and community entities. These could include hospital care management, nursing facility care management, home health services, post-acute programs, community-based services, and payer-provided disease management/case management programs. This ensures the patient is aware of the resources available and that the resources are coordinated and efficiently deployed.
The Sequent culture of continuous quality improvement is led by the Sequent Quality Committee, which is comprised of Sequent physician members that represent multiple specialities. The Quality Committee determines the quality improvement practices are performed consistently across the Sequent Network and leverages data on these evidenced-based practice guidelines to identify opportunities for improvement. This committee is also responsible for building care pathways to guide movement between settings and providers. These pathways ensure timely access to high quality speciality medicine where appropriate and map the flow of clinical information for integration.
Care Coordination
A secondary function of the Care Coordinators is to ensure referrals occur in a timely manner and that all relevant reports are available for the provider prior to the visit. Additionally, the Sequent Quality Committee identifies care standards and care pathways to ensure best practices and appropriate handoffs occur consistently across the Sequent Network. As Sequent practices provide feedback to the clinical team, the Quality Committee works to identify opportunities to expand the clinical measurers and/or build new clinical pathways. These clinical pathways are intended to guide movement between settings and providers, including the exchange of information. The McKesson Population Manager system also provides tools of care coordination by giving providers and their staff information on recent visits to the hospital or specialists who are members of the network.
One of the roles that RN Care Managers will take on in the future is to assist with transitional care outreach and post-hospital discharge. Transitional care activities focus on ensuring patients understand their discharge plan, coordinate post-discharge appointments, and comprehensive medication reconciliation. These calls occur within 48 hours of discharges and performed by a Registered Nurse. Additional outreach occurs to the patient's primary care provider to ensure the flow of information between the hospital and the community primary care practice. This also allows for additional follow-up activity requiring physician coordination to be completed in an efficient and effective manner, The goal for the process is to secure a primary care office visit (or with an appropriate specialist) within 7 days of discharge from the hospital. As is the case with all outreach to patients, the clinical team members reminds the patient of the after-hours policies and office hours of the practice, emphasizing that a primary care provider from the patient's practice is available 24 hours a day via their answering service.
Care Guidelines and Quality Performance
Individual provider and practice performance on metrics identified by the Quality Committee are shared through performance dashboards. These dashboards include performance on quality and utilization measurers. Along with these dashboards, practices are provided guidance from the Sequent Clinical Team about potential opportunities for improvement given their current performance and patient population. Along with high-level metrics, the clinical team has tools to drill down to the patient-level in order to identify patients driving high and/or inappropriate utilization as well as the patients with identified gaps in care. The team works with the practice to determine appropriate changes to current workflows in order to improve in identified measurers. The overall goal of this process is to determine the system issues leading to gaps in care or barriers to care. Once potential barriers are identified, the team works with in the practice to determine new, evidence-based standard work or system changes that will help provide better care and improve practice efficiency.
Over time, impacts of these changes are measured by monitoring the dashboards to quantify the degree of improvement. The network tracks performance overtime to determine if the change had the intended impact. When the expected impact does not occur (or does not occur to the degree to which was expected), the team will work to make small tests of change to the plan to determine which activities produce the largest impact. Thus, tracking quality and utilization metrics gives the practices a new tool to measure the impact of new workflows.
In addition to using metrics for quality improvement, it is also a tool used measure individual provider performance. Providers and practices are held accountable for their performance via oversight by the Quality Committee. The committee reviews performance to determine practices or physicians who are outliers within each measure. When outliers are identified, resources are provided to assist poor performing outliers in activities to improve their performance. On the other hand, when high performers are identified, the team seeks to learn more about the drivers of their strong performance in order to spread their innovative tactics to others within the network.
All of this quality improvement activity requires a high degree of engagement from the practices within the network. Engagement with the clinical team and the quality improvement process is paramount to success, thus engagement is tracked very closely. Groups identified as displaying low engagement are discussed at physician leadership meetings. Physician leaders perform peer-to-peer outreach to discuss the current issues and engagement requirements moving forward. This process allows an unengaged group to hear directly from a trusted colleague who is leveraging the data and resources well. Should provider continue to display poor levels of engagement, the provider will potentially be further educated., coached, penalized and/or terminated from the network.
