Sharron Rushton1, Debbie Murray, Charles Talley, Sandra Boyd, Kern Eason, Marian Earls, Paula Tanabe. 1. Sharron Rushton, DNP, MS, RN, CCM, CNE, is an assistant clinical professor of nursing at Duke University School of Nursing. She serves as faculty leader for the Population Care Coordinator Program and is experienced in care coordination. Scholarly interests include collaborations, interprofessional education, population health, and care coordination for biologically and socially vulnerable populations. Debbie Murray, RN, CMAC, CHC, CPN, CNM, is the director of Population Health Outreach and Care Coordination Services at CCNC. Her team of health educators and health coaches works to make sure that all patients have the access to appropriate care and the resources needed to improve self-management of their health concerns. Charles Talley, BS, is a health educator in Population Health Outreach and Care Coordination Services at CCNC. He maintains the sickle cell referral database and contacts patients following their visit to the ED to ensure that they have access to appropriate care and the resources needed to improve self-management of their health concerns. Sandra Boyd, MA, is the NC Sickle Cell Syndrome Program supervisor. Her team of educator counselors provides counseling, care coordination, and education to individuals with sickle cell disease and their families throughout the life course. Sandra works with her team to ensure that patients with sickle cell disease who visit an emergency department are contacted within 3 days of receipt of a referral by a CCNC care manager. The program's goal is to ensure that each client has a plan of care, is connected with a primary care provider and hematologist, and is linked to resources necessary that help improve his or her quality of life. Kern Eason, MBA, is the pediatric program manager at Community Care of North Carolina. He oversees CCNC Pediatric Program activities, particularly in coordination of CCNC's systems, practice, and patient-facing work on behalf of patients with sickle cell disease. Kern has specific skills in pediatric information technology and sees this as a key driver of quality in pediatric health care. Marian Earls, MD, MTS, FAAP, is the director of Pediatric Programs and deputy chief medical officer for Community Care of North Carolina and has led the CCNC Sickle Cell Project since 2013. She is board-certified in both General and Developmental & Behavioral Pediatrics. She is a clinical professor of pediatrics for the University of North Carolina Medical School. Paula Tanabe, PhD, MSN, MPH, RN, FAEN, FAAN, is a professor in the Schools of Nursing (SON) and Medicine at Duke University. Dr. Tanabe is the associate dean for Faculty Development and Data Science, SON. Her program of research is focused on improving systems of care, health outcomes, and quality of life for individuals with sickle cell disease.
Abstract
PURPOSE OF STUDY: The purpose of the project was to describe the implementation and evaluation of a care management referral program from emergency departments (EDs) to care management services for patients with sickle cell disease (SCD). PRIMARY PRACTICE SETTING: Patients were referred to Community Care of North Carolina (CCNC), which is a private-public collaboration providing care management services and served as a referral hub for the program. Patients received follow-up from either CCNC or the North Carolina Sickle Cell Syndrome Program. METHODOLOGY AND SAMPLE: A multidisciplinary, multiorganizational group streamlined the referral process for patients with SCD who have ongoing care needs by linking patients from the ED to care management services. The article presents a review of program implementation and evaluation over a 3½-year period. The target population were patients who had a diagnosis of SCD and presented to the ED for treatment. Emergency department staff used a modified version of the Emergency Department Sickle Cell Needs Assessment of Needs and Strengths tool to screen for social behavioral health needs in areas such as emotional, financial, pain management, and resources. All forms were faxed to a central number at CCNC for follow-up care management services. Community Care of North Carolina then linked the patient with the appropriate agency and staff for follow-up. RESULTS: More than 900 referrals were received in 3½ years. Pain was the most common reason for referral. An increase in care management intensity was observed over time. All levels of care management intensity saw an increase in the number of patients. IMPLICATIONS FOR CASE MANAGEMENT: Care management occurred across organizations after careful planning among stakeholders. The interagency cooperation permitted the development of a streamlined process. In particular, the creation of a single point for referral was an important component to allow for population-level monitoring and ease of making referrals. Patients with ongoing care needs were identified and there was an increase in the intensity of outpatient care management services delivered.
PURPOSE OF STUDY: The purpose of the project was to describe the implementation and evaluation of a care management referral program from emergency departments (EDs) to care management services for patients with sickle cell disease (SCD). PRIMARY PRACTICE SETTING: Patients were referred to Community Care of North Carolina (CCNC), which is a private-public collaboration providing care management services and served as a referral hub for the program. Patients received follow-up from either CCNC or the North Carolina Sickle Cell Syndrome Program. METHODOLOGY AND SAMPLE: A multidisciplinary, multiorganizational group streamlined the referral process for patients with SCD who have ongoing care needs by linking patients from the ED to care management services. The article presents a review of program implementation and evaluation over a 3½-year period. The target population were patients who had a diagnosis of SCD and presented to the ED for treatment. Emergency department staff used a modified version of the Emergency Department Sickle Cell Needs Assessment of Needs and Strengths tool to screen for social behavioral health needs in areas such as emotional, financial, pain management, and resources. All forms were faxed to a central number at CCNC for follow-up care management services. Community Care of North Carolina then linked the patient with the appropriate agency and staff for follow-up. RESULTS: More than 900 referrals were received in 3½ years. Pain was the most common reason for referral. An increase in care management intensity was observed over time. All levels of care management intensity saw an increase in the number of patients. IMPLICATIONS FOR CASE MANAGEMENT: Care management occurred across organizations after careful planning among stakeholders. The interagency cooperation permitted the development of a streamlined process. In particular, the creation of a single point for referral was an important component to allow for population-level monitoring and ease of making referrals. Patients with ongoing care needs were identified and there was an increase in the intensity of outpatient care management services delivered.
Authors: Paula Tanabe; Audrey L Blewer; Emily Bonnabeau; Hayden B Bosworth; Denise H Clayton; Nancy Crego; Marian F Earls; Kern Eason; Grayson Forlines; Gary Rains; Matthew Young; Nirmish Shah Journal: J Health Econ Outcomes Res Date: 2021-04-01