PP09 – The Journey on Closing the Knowledge Gap on Care Coordination: From a Nursing Perspective
Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) formed partnerships with primary care practices that were designated as patient-centered medical home (PCMH). Registered nurses spearheaded efforts in practice transformation and care delivery from a fee-for-service to value-based care. The population health nurses at Horizon BCBSNJ evolved into the Care Transformation team which focused efforts on supporting care coordinators with quality improvement initiatives and workflow processes. As PCMH practices have expanded into advanced value-based programs, a significant gap in knowledge has emerged among population health care coordinators.
An evaluation tool was used to measure population health concepts among registered nurses in care coordinator roles in the primary care setting. The results revealed a wide gap in knowledge on topics that include transitions in care and social determinants. The Care Transformation team began to offer customized training for the novice, intermediate and expert population care coordinator. There was a paradigm shift in developing education programs for various levels of experience so that nurses received education that was tailored to their individual learning needs.
More than 1.5 million Horizon BCBSNJ members currently participate in one of the patient-centered, value-based programs. The Care Transformation team is responsible for developing education and training programs for care coordinators across the state of New Jersey. The 2016 outcomes data for members receiving care from PCMH providers with care coordinators compared to members receiving care from traditional primary care practices show that PCMH members had an overall 8% higher rates for preventative screenings and 7% reduction in emergency room visits and hospital in-patient visits. Care Transformation team focused education efforts that led to delivering more cost-effective and efficient care, which helped to lower total cost of care and improve quality outcomes.