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Oncology Practice Management - November 2013, Vol 3, No 7 - Practice Management
Sheryl A. Riley, RN, OCN, CMCN

The healthcare market has begun to redefine or change the qualifications of the care coordinator/manager. This new definition is not being driven by the new care models, service changes, or qualifications. Simply put, it is because of financial reimbursement, government regulation, and subsidies.

For the first time in years, the clinical delivery models are moving in the right direction. They are focused patient-centered care, including the family or caregivers as well as education and wellness. Another benefit of the new models is the support of a strong physician/patient relationship, which is strategic to driving patients and their families toward self-care and wellness.

Consequently, with all of the focus on the patients, wellness, education, and community-based medicine, why would physician practices move away from using registered nurses (RNs) and transition to social workers or nonclinical staff as the care coordinator/manager for the patients? More than likely it is because of the cost difference between an RN and a social worker and/or nonclinical personnel.

There can be no doubt that both social workers and nonclinical staff members are vital members of the care coordination/management team and serve a significant function; however, neither of those roles can fulfill the clinical responsibilities or have the clinical training and knowledge level of a highly qualified RN. Nor are they qualified to educate the patient on evidence-based medicine, medication compliance, drug interactions and side effects, preventive medicine, exercise, nutrition, and urgent or emergency care.

The Current Landscape

The government continues to cut the physician reimbursement yearly but, conversely, increases the requirements and regulations that physicians must follow. In the past 3 to 5 years, the government has poured billions of dollars into new regulations, requirements, and qualifications. The following represents just a sampling of new requirements.

  • All physicians need to convert all paper records to an electronic medical record (EMR) by 2015, supported by the federal government.
  • All billing for the Centers for Medicare & Medicare Services must be electronic by 2015, supported by the federal government.
  • For physicians to qualify for meaningful-use dollars, they must meet 32 standards in regard to software, patient satisfaction, and other quality metrics.
  • Transitions of care, care coordination, and community outreach are all supported by money from the federal government.

Because of the lack of any specific requirements in regard to how these improved quality standards are met, and without guidelines recommending the use of highly trained and qualified RNs to support the model, many practices use “other” professionals or even nonclinical professionals in that role. To put it bluntly, “you get what you pay for.”

The American Nurses Association released a white paper in 2012 with hard and soft data that lends credence to the idea of using RNs for the care coordinator/manager position. Because the recent standards have forced physicians as well as all other fields of healthcare to be more concerned about their “bottom line,” it might be prudent to compare some numbers. Social workers make between $35,000 and $65,000 depending on the region of the country, and nonclinical personnel make between $20,000 and $40,000. This may appear to be a cost-savings at first, if you only consider the dollar figure and not the value each brings to the practice. Conversely, highly qualified RNs with a strong clinical and managed care background will cost between $55,000 and $100,000 depending on the region of the country and the role they are required to fulfill.

At first blush it might give you sticker shock, but the return on investment is great when considering that, in the long run, RNs may save you money through more effective and efficient navigation of the healthcare system for your patients. Educated and trained professionals with clinical specialties such as oncology, chronic care, diabetes, heart disease, and mental health will cost more than a social worker or a nonclinical professional, but for good reason.

RNs have skills and expertise in patient education, medication and symptom management, care management, coordination of services, and resource and care coaching. The RN can speak with patients and their families on topics that physicians may not be as comfortable with or do not have the time to discuss because of increased demands under the new system to see more patients in a shorter period of time. Such topics may include medication management, weight loss, and smoking cessation, as well as palliative and end-of-life care. The RN can follow up with the patient after the physician visit and explain the treatments, medications, and laboratory and screening tests. They can make follow-up phone calls, hospital visits, and home visits if warranted. They are, in a sense, “physician extenders” who not only communicate the physician’s plan of care to the patients and their families, they educate and teach the patients how and why they should follow the treatment plan. Nurses can then communicate all of the findings to physicians through the EMR and daily communication.

As a profession, nursing is considered extremely trustworthy and patients may feel more comfortable speaking to nurses rather than physicians about certain aspects of their care. By connecting with patients early in the care management process, it decreases the amount of calls, e-mails, and patient follow-up that physicians have to do themselves.

Nurses continue to come out on top of all professions—as well as physicians and pharmacists—as the most honest, ethical, and trusted of professionals. Nurses give patients a feeling of security and trust that improves patient compliance and satisfaction, decreases emergency department visits and urgent hospitalizations, and improves communication with referrals and transitions to hospitals, home care, and skilled nursing facilities.

In this new world of quality metrics, regulations, and subsidy dollars directed to only the best practices, the question you need to be asking yourself is, can you afford not to hire an RN for the care coordinator/ manager in your practice?

About the Author

Sheryl A. Riley is the director of clinical services for SAI Systems, a technology consulting services and solutions company based in Shelton, Connecticut. She can be reached at sriley@saisystems.com or by calling 203-929-0790.

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