Coordinating Diabetes Care on a Payer's Behalf

Mary Ellen Wolf, BSN, RN, CDE, has been a diabetes educator for more than 20 years, but in 2014 her role changed: she joined Healthways, which contracts with insurers to bring the patient-centered medical home (PCMH) model into primary care practices.

She’s now a care coordinator, charged with identifying those patients in the health plan who are using care in a fragmented way. Once found, both the patient and the primary care physician (PCP) must be put on a new path of using the right amount of care in the right places. It makes Wolf a foot soldier in the quest to “bend the cost curve” in healthcare spending, which CMS estimates could consume 19.6% of the economy by 2024.

Her talk, “Can Diabetes Educators Be Care Coordinators?” took place on the first day of the annual meeting of the American Association of Diabetes Educators (AADE), which meets through Monday in San Diego, California.

The idea of the Patient Centered Medical Home (PCMH) originated in 1967, but it took years for the delivery model to pick up steam, before it was folded into the Affordable Care Act in 2010. While healthcare costs are driving the shift, PCMH isn’t just about saving money—it’s about bringing more accountability to the system.

Wolf’s basic tasks include working PCPs and nurse practitioners to keep patients out of the hospital or ending up with a cabinet full of medicine they don’t take. Most of the savings from care coordination, she said, come from reduced hospital admissions and fewer visits to the emergency room (ER).

She describes the combination of an aging population and the ACA bringing new wave of patients into primary care as a “perfect storm” to drive new delivery models, PCMH among them. “When this is done correctly, it generally produces a higher quality of care at a lower cost,” she said. And, “It’s a better experience for the patient and the provider.” - See more at: http://www.ajmc.com/conferences/aade2016/coordinating-diabetes-care-on-a-payers-behalf#sthash.K0ly54Ej.dpuf