Care Coordination Team Update

The close of a calendar year provides a great opportunity for our team to reflect upon what we have accomplished. We are grateful for the partnerships we’ve established with our primary care practices and look forward to again working closely in 2019. We now have 10 practices taking part in the Alliance Medicare Care Coordination program and 28 practices involved in the Commercial Care Coordination programs. We have witnessed improvements in the vast majority of our quality metrics during the past year which is in part due to the information sharing and collaboration taking place under these programs.

The Alliance nurses continue to support transitions of care when patients are discharged from acute hospitals and post-acute facilities. They also support development of improved self-management skills in Alliance patients who are dealing with chronic diseases. In 2018, the six Alliance nurses had over 17,000 encounters or “touches” with nearly 3300 patients. The engagement rate with these patients was 77% and over 60% of them met their program goals. We are anxious to fine tune our care coordination processes in the New Year so we can more accurately identify the actions that best support improved patient outcomes.

As part of the Triple Aim, we strive to improve patient experience and it’s been gratifying to receive phone calls, letters and verbal anecdotes about the relationships among the Alliance nurses and their patients. Although this side of patient care is often difficult to quantify, here are a few snippets from our patients that offer some perspective:

“Your nurse has been so wonderful to call me. I was a patient In Mary Washington Hospital a few months ago and she calls me about every 3 weeks. Thank you so much for allowing a nurse like this to follow me. This service is great because (your nurse) discusses my medications, reminds me of my appointments and gives me her undivided attention. I feel better about myself and my medical care because of her”

“(Alliance Nurse) seemed extremely knowledgeable about the various specialists we have seen over the past few months. He listened carefully and thoughtfully to my explanation of the course of action we had taken to deal with my mother’s issues. He offered very appropriate suggestions for next steps. He didn’t make me feel foolish for my exhaustive account of our medical experience. I honestly couldn’t believe someone sincerely cared about my mother’s well-being in the medical system”

“I want to extend a special thanks to (Alliance nurse) for the many calls expressing concern and giving words of encouragement and assurance. Your caring demeanor, calm and soothing voice were truly welcomed and deeply appreciated. Certainly, I am grateful for your professional advice and resourcefulness which provided invaluable support as well as a sense of hope and strength”

Many thanks to the primary care practices for taking calls from the Alliance nursing team, and allowing us to work along side of you in support of high quality patient care.

Categories: MWMD Newsletter