Care Coordination Lessons Learned Print
Rural Health Care Coordination Network Partnership Program

Executive Summary: The Southeast Rural Physician Alliance-Independent Physician Association (SERPA-IPA) is a Network that started this program with 11 rural clinics, one of these clinics being a Rural Health Clinic. Since the beginning of this project SERPA-IPA, now known as Southeast Rural Physician Alliance - Accountable Care Organization (SERPA-ACO) comprises 13 rural clinics and 3 non-rural clinics. Data was not collected for then non-rural clinics. SERPA-ACO clinics in the PCMH initiative made up the care coordination Network for this grant. SERPA-ACO was the lead grantee for the Rural Care Coordination grant and the fiscal administrator. SERPA-ACO worked with each clinic in developing a Care Coordination Program. Each clinic was responsible for hiring care coordinators to meet the needs of their patient population. The clinics developed their policies and procedures for the program with the help of SERPA-ACO. SERPA-ACO provided different methods of training and resources for the clinics as they built their care coordination programs. This program looked at rural populations of the elderly, 65 years and older and Hispanic/Latinos with a diagnosis of diabetes and/or congestive heart failure (CHF). The diagnosis of heart failure did not seem to be significant among this group of patients. The thinking was that most patients with a diagnosis of congestive heart failure did not routinely see a rural family practice physician.
Background and purpose: The purpose of this assessment is to review the findings of the Rural Health Care Coordination Partnership Program that SERPA-ACO participated in for three years. SERPA-ACO member network consist of 13 rural clinics and 3 non-rural clinics. The 3 non-rural clinics participated in the project, but data was not collected from these clinics.   Most of our communities are in rural Nebraska, representing many of the counties throughout the state. Rural areas in Nebraska are experiencing an aging population due to the increase in the number of youths that are migrating to urban areas. The population 65 and older in the service area is 19.45%, significantly higher than the state rate of 13.9%. As these citizens age, their healthcare needs become both more prevalent and more critical and the rate of diagnosis of both diabetes and cardiovascular disease increases dramatically. Due to fewer young people staying in the communities and an older population of health care providers, the availability of healthcare providers is also decreasing. The average age of rural practitioners is older compared with urban areas, and with many expected to retire in the coming years, communities are struggling to recruit and retain younger providers to replace them. Nebraska has a rapidly growing minority population increasingly comprised of persons of Hispanic/Latino origin. In certain pockets of the service area. Hispanic populations make up 32.3% and 21.9% of the total population, respectively. Many of the clinics in the network have meat packing plants that employee large numbers of Hispanics/Latinos. This population has a high incidence of diabetes. The growth of this population brings unique challenges to the rural areas for related to socioeconomic issues and language barriers. This has created a burden on the rural clinics by creating a need that is difficult to meet as there is a severe shortage of healthcare workers with the cultural and linguistic skills needed to provide to this population. Nebraska ranks 46th out of the 50 states with a disparity value of 36.1 as compared to the number one state of 15.5. Residents of rural areas typically have a lower education level and lower income than their urban counters, an independent risk factor that increases the burden of disease both on the population and on the already fragile rural healthcare system. This program was designed to address the needs of rural Nebraska to reach patients that have a diagnosis of diabetes and/or congestive heart failure. Due to Nebraska being primarily a rural state, the need for a care coordination program became evident. Rural areas are experiencing an aging population, and the accompanying increased disease burden that comes with it. One in 6 adults have a diagnosis of diabetes, and heart disease is the second leading cause of death. SERPA-ACO adopted the North Carolina Coordinated Care model. This model did not work as well with the clinic setting, as it was more hospital based and more structured than we wanted for our program. SERPA-ACO adapted this model to fit our needs. We worked with each clinic within the network to create a team-based care model, where the clinic staff understood the roll they played in the PCMH. Care Coordinators became the point of contact for patients/family members. They followed their patients with diabetes and CHF on regular basis. The care coordinators reached out to other services/agencies within their communities to improve patient care, including hospitals and specialists to improve communication. The clinics worked to develop long-term continuous relationships with their patients to help them understand their disease process and to encourage participation in their care, with the hope of intervening with evidence-based care to prevent complications.
Assessment methods: Data Collection was a challenge for the Network. A data base to collect aggregated data has been a challenge to the Network due to having eight different EHRs. SERPA-ACO has worked with different Health Information Exchange (HIE) data programs and had not had success in finding a data base that would work with all the EHRs. Collecting data from the care coordinators on the patients that they touch daily became very time intensive along with collecting ethnicity, race, age, and type of insurance which added an increase burden of time spent and impacted the accuracy of data collected. SERPA-ACO developed a care coordinator log from an excel spreadsheet to try to help the care coordinators by spending less time collecting data, however, they were still required to manually input this information. From these care coordinator logs data was collected. SERPA-ACO does not feel that this gave a good clear picture of the success that was achieved from this program. Outcomes that we have seen from the results of our Care Coordination grant are numerous. Each clinic in the network started with either no care coordinator at all or a staff member working part time in this role. Since the beginning of the grant, clinics have added at least one to three full time care coordinators. Some of the clinics have also added social workers, CHW's, diabetic educators, and clinic data specialists. The clinics report that they are seeing an improvement in relationships between the provider's team and patients/families with patients being more willing to participate in their care. Patients are responding to phone calls and letters that are sent out by the clinics for reminders of missed routine visits and follow up visits on their disease related issues, particularly diabetes. The Network clinics have approximately 6523 diabetic and CHF patients. Due to the inability to collect accurate data it is estimated that approximately 80% of these patients are touched by the care coordinators. The clinics have developed new ways of organizing and delivering care, improving quality processes, assessing patient needs, developing referral systems, and goal settings. Some of have clinics have worked with their local hospital and developed a working relationship with them that was not there before the start of the care coordination program.The Network clinics have achieved shared savings by being part of a PCMH with a private insurer. This savings is due mainly to the work that the Care Coordinators are doing to prevent rehospitalizations and ER visits. Also, the care coordinators work with their diabetic patients and CHF patients to meet quality measures to improve their disease state.
Dissemination of project findings:This grant findings were disseminated throughout the SERPA-ACO network.  As lessons were learned the care coordinators in the clinics would share their experiences with each other through our joint communications platform and through network meetings. This led to great understanding of work flow and best practices in the clinic setting. SERPA ACO staff did presentations about the network and care coordination at national and state meetings.  Joleen Huneke, CEO presented at the National Association of ACO's in Washington DC on April 2018.  She also presented at the MGMA Operations Meeting in Austin, TX on April 15, 2019.  Dale Michels, CMO presented at the Nebraska Medical Association and Nebraska Rural Health Association during 2018 and 2019.  Janet Steffen, Grant Administrator and Heidi Jezbera, Clinical Integration presented at the Nebraska Rural Health Association in May 2019. During the spring of every year we did exhibits at the Nebraska Academy of Family Physicians. Care Coordination lessons has always had a key role in these meetings. 
Conclusion and recommendation:This grant project was very valuable to the clinics in SERPA-ACO for developing care coordination programs in their 13 clinics (3 of those clinics did not share data in this project due to not being a clinic in a rural area but was included in the training). SERPA-ACO believes that the population that was identified, being the elderly over 65 years of age and Hispanics/Latino were impacted by this program because the clinics were able to create and build a care coordination program around these patients that had a diagnosis of diabetes and/or congestive heart failure (CHF). The clinics extended this program to reach all their patients and all diagnosis. Data collection for this program was difficult due to not having a data base that could interface face with the 8 different EHRs among the clinics in the network to provide aggregated data. An excel log sheet was created for the care coordinators to manually collect this data which was not ideal since it took time away from patient care and resulted in inconsistent data. The clinics within the SERPA-ACO network have continued with their care coordination program. They are being sustained by participating in shared saving programs by insurers. The clinics within the SERPA-ACO network has seen a complete evolution of patient care that they will continue with a care coordination program.