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Nurse Manager Reports Successes With CCO Pilot in Florence

March 1, 2013 -- “Frequent flyers” – those patients who use the emergency room often – are a hot topic in healthcare policy talks both in Oregon and nationwide, as policymakers strive to bring down costs by identifying these patients and investing in preventive care to keep them out of the hospital.
March 1, 2013

 

March 1, 2013 -- “Frequent flyers” – those patients who use the emergency room often – are a hot topic in healthcare policy talks both in Oregon and nationwide, as policymakers strive to bring down costs by identifying these patients and investing in preventive care to keep them out of the hospital. 

While newly-formed coordinated care organizations are working to determine the nuts and bolts of transformation, some preliminary data are already in from a pilot project on the Oregon coast that has been working toward the goals of the CCOs for the past 18 months.

Sylvia Pishioneri, an RN coordinator at PeaceHealth in Florence, where Oregon Health Plan members are now enrolled in Trillium Community Health Plan, talked to a crowd of about 100 people – most either nurses or nurse-managers – about the lessons, successes and challenges of a pilot project to coordinate care in her community at the Oregon Center for Nursing's Leadership in Nursing Conference recently.

“I can see a lot of my patients doing better and feeling better,” Pishioneri said.

The PeaceHealth pilot assigned a group of four nurses to work with patients identified as “high risk,” to talk to them about proper self-care and communication with providers. Pishioneri said she tells her patients, “Call me before it gets bad.” Diabetic patients have learned to call her if they gain a few pounds suddenly or their blood sugar is suddenly too high, rather than wait until they are very ill and require a hospital visit.

“High risk” patients were defined as those who had visited the emergency room more than six times in the last six months, had more than three in-patient visits during the last three months, had poorly managed diabetes, or had diabetes and a co-occurring mental health diagnosis or a diagnosis of hypertension, according to criteria released by Pamela Hight, who works in process design and improvement at PeaceHealth. Those criteria are released in order of priority, with patients who had visited the ER more than six times in the last six months being considered the highest risk.

Pishioneri said many of the patients she worked with in the pilot project have low health literacy, and may have cognitive or mental health problems making it difficult for them to communicate with providers, so she has also helped them improve their communication skills and comfort level talking to doctors.

A lot of monitoring takes place through routine phone calls to see how patients are doing, she added. The frequency of check-ins depends on the patient's diagnosis and how “high risk” he or she is considered to be – with lower risk patients only receiving calls once a month or once every two months.

Some barriers to good outcomes included non-adherence to treatment, sometimes due to patients being unable to afford medications, lack of health literacy, change of condition in lifestyle, as well as lack of resources. While the 15 CCOs in Oregon take care of Oregon Health Plan members, the pilot – which started in 2008 with a $28,000 per year grant from Regence BlueCross BlueShield and continued in 2010 with a federal grant of $100,000 per year – serves a mix of patients, including those who are uninsured and receive assistance from the hospital's charity care program, as well as people on Medicare and Medicaid.

Despite those barriers, Pishioneri said there were several success stories. One patient, a 38-year-old woman with asthma, didn't know how to use her inhaler, so Pishioneri changed her medication, and now the patient is doing much better and visiting the hospital less often.

She’s also advised nurses to meet patients where they are, be willing to advocate for the patient to providers and insurers, set boundaries, listen and be accountable.

Setting boundaries can be particularly difficult, she said. “Some patients have stories that will break your heart. I don't make promises to anybody. I don't compromise my ethics,” Pishioneri said. “When you can't do anything else, be kind.”

One audience member asked if there is ever a time when patients become accountable enough to “fly on their own,” and Pishioneri said some of her patients had “graduated” from the pilot program. Most of the successful cases have been diabetic, she said, and they still get check-in calls once or twice a year.

Pishioneri said the program was estimated to have saved about $1.5 million, a figure that coordinators arrived at by comparing revenue from emergency room visits and looking at funds requested from the hospital's charitable assistance program.

PeaceHealth officials were not able to provide the number of patients served by the pilot program in time for The Lund Report's deadline.  

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