Purpose of the study: The purpose of this intervention was to answer the following question: Does an embedded nurse case manager from a health plan performing embedded care coordination and supporting a quality improvement project impact medical home service use, role satisfaction, and per member per month expense?
Primary practice setting(s): The setting for this study was primary care medical home practices with a minimum of 1,000 lives, contracted with a health plan delivering Medicaid and Children's Health Insurance coverage.
Methodology and sample: Five medical home practice sites were selected for the intervention. The study began with case manager training and project permission in 5 medical homes, followed by implementation of care coordination with health plan clients. The nurse case manager performed care coordination functions for clients and initiated a Lean Six Sigma quality improvement project at the medical home site. The analysis strategy was to compare each medical home with itself before and after the intervention, as well as to obtain satisfaction information from medical home staff and care coordinators.
Results: Reductions in expense, as demonstrated by decreased per member per month claim cost, admissions per thousand, and reduced variation in days per thousand, were documented. Quality projects attained significant improvements in 4 out of 5 sites, and practice staff as well as case managers described satisfaction with the embedded nurse case manager role. These findings support medical homes as being an effective delivery model of the Affordable Care Act.
Implications for case management practice: Case managers who practice in primary care sites can make a significant difference in patient outcomes and practice efficiencies. Embedded case managers have the ability to impact the population being served through modeling and supporting interprofessional relationships and case management expertise. Use of motivational interviewing, assessment skills, advocacy, and joint care planning engage patients in their own care, whereas quality initiatives bring efficiencies and effectiveness to overall operations. There is need for research to be conducted across a larger number of practice sites and diverse populations to substantiate the effect of embedded case management in medical home.