Health plans and providers alike have been touting the benefits of incorporating “embedded nurses” or care coordinators into their ACO framework, reporting that they contribute to improved patient outcomes by providing a significant communication link between the patient and physician. In unveiling recent ACO ventures or achievements in both the Medicare and commercial space, insurers such as Aetna Inc. and Cigna Corp. have highlighted these caregivers as pivotal to the success of their accountable care models.

“It’s the care coordinator — in almost all cases a registered nurse — who uses the patient-specific data we send to our ACO physician practice partners for outreach calls and follow-up care,” Cigna spokesperson Mark Slitt tells ABN. Cigna, in announcing various new ACO agreements in New York (see brief, p. 12) and New Jersey, has cited these care coordinators as an important part of the health system delivery models.

Care coordinators use the Cigna data “to identify patients being discharged from the hospital who might be at-risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill,” Cigna has said in prepared statements. These caregivers also work with the patient’s physician to help patients get needed follow-up care or screenings, identify any issues related to medications and help prevent chronic conditions from worsening.

Aetna also has cited its “embedded” nurse case managers, who help coordinate care for its Medicare Advantage (MA) members, as a factor in improving health outcomes in several of its Medicare ACO-type provider collaborations (ABN 1/12, p. 7).

Nurse case management is an area which can provide “a tremendous contribution to not only our members/patients, but it’s also an area of opportunity for the nursing profession,” Randall Krakauer, M.D., national medical director for Aetna’s Medicare business, tells ABN.

Embedded Nurses Are ‘Extensions’ of Offices

In explaining how an “embedded” nurse could support an ACO, Nancy Boerner, M.D., chief medical officer at Monarch HealthCare, an Irvine, Calif., independent practice association, says the nurse essentially operates as an extension of a physician’s office, becoming the knowledge base of what’s available external to that office. Monarch was one of 32 participants chosen in December for CMS’s Pioneer ACO program (ABN 1/12, p. 1).

“The physician and the staff then become familiar with this nurse and her capabilities and she becomes the liaison who understands the practice,” augmenting what the office doesn’t have the capability to do, Boerner says.

There some models where practices “physically embed” a nurse who is actually part of the team and who goes to the practice on a regular basis, Boerner says. An alternative is to have a “virtually embedded nurse” at a different office site, who interacts over the phone but isn’t there on a regular basis, she says.

Monarch now uses the virtual model. “So they’re embedded virtually, where they get to know the doctor and his practice and help to coordinate care for patients.” In her view, the true model of an embedded nurse is someone who is actually physically in the office with the physicians. “It’s not the model we currently have, but we would like to work toward” that, she said.

Aetna Has Used Case Managers for Years

Krakauer says Aetna’s embedded nurse program grew out of its nurse case manager program, “which we’ve had for some years now, particularly in our Medicare population. In terms of management of chronic illness or multiple chronic illness, the case manager nurse is extremely helpful in generating a tremendous impact, particularly with advanced illness.”

For Aetna, “embedding a nurse” means working with a provider group, whether it’s a primary care or multispecialty group, and coming to some type of agreement to use “their best efforts and our best efforts to focus on mutually agreed upon, desirable quality outcomes,” Krakauer says.

Studies have shown that there simply isn’t the level of confidence in physician offices that all patient tests, consults and prescription orders are going to get done, as opposed to an inpatient hospital setting, Krakauer contends. While Aetna can’t create a hospital inpatient situation, “We can do a great deal to improve the ability of physicians to get this work done.”

If the embedded case manager is right there in the office, a physician can go see her and say, “I just saw Mrs. Jones and I want her weight checked twice a week and if it goes up more than a kilogram, I want to know about it. I want to make sure she’s filling her prescriptions. Make sure she gets this lab work done, gets this consult, and make sure she’s back at six weeks and keep in touch with her,” he illustrates. The end result is more complete care, he adds.

Through this process, the nurse case manager starts to seem like another member of the medical group team. “Even though she’s our employee, she has to create the feeling that she is their case manager in order for this to work. So, she not only has to do her job, but create that kind of relationship.”

Krakauer seems optimistic that Aetna, which recently announced ACO agreements with Sharp Community Medical Group and Banner Health, will incorporate embedded nurses into its commercial models. It has already been proven to work in the MA space, with demonstrated results, he says. “I believe you will see these incorporated into ACO plans with some of our existing partners.”

ACOs Need Finance-Savvy Nurses

Catherine Garner, R.N., dean of health sciences and nursing at American Sentinel University, says it’s not surprising that nurses are taking on a more important role in emerging health system delivery models. ACOs signal a different kind of health care system, one that requires nurses who are smarter about finance and stewardship of resources, Garner said in a prepared statement late last year.

“In the ACO model, hospital nurses must understand the ‘whole patient’ beyond the hospital walls, and nurses in the community must effectively communicate to keep people out of the emergency rooms.”

Once seen as a profession with a shortage problem, a December 2011 Health Affairs article pointed to resurgence in the nursing field. “Aggressive efforts to make nursing a more attractive career choice have helped spur a 62% increase in the number of younger nurses (ages 23–26) entering the field between 2002 and 2009. As a result, rather than declining as previously projected, the registered nurse workforce is now expected to grow at roughly the same rate as the population through 2030,” the article stated.

Program Offers Studies on Reform

American Sentinel, an online university based in Aurora, Colo., is now offering a BS degree program for nurses that want to expand their knowledge base to meet current health reform initiatives such as ACOs. Looking at the ACO-type models that are successful, such as Geisinger Health System or the Cleveland Clinic model, “nurses are intimately involved in patient management, in patient follow-up, case management in the community,” Garner tells ABN.

“And that’s the role that’s going to be critical. If you’re going to accept risk — and that’s essentially what accountable care [does] — folks are going to have to look to nurses and to the expertise they bring to the table to manage that population.”

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