Online Program

Development of a nursing scorecard to track population metrics for care coordination of highrisk patients in primary care

Monday, November 2, 2015 : 9:10 a.m. - 9:30 a.m.

Mary Blankson, DNP, APRN, Community Health Center, Inc., Middletown, CT
Daren Anderson, MD, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Kathleen Thies, PhD, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Khushbu Khatri, BS, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Nicholas Ciaburri, BS, Business Intelligence, Community Health Center, Inc., Middletown, CT
Deb Ward, RN, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Ianita Zlateva, MPH, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Background: Tracking population metrics of nurse-driven care coordination for high-risk patients in primary care can help to identify the impact of care coordination on clinical measures for these patients. Tracking also reveals how many care coordination patients a nurse in primary care can support at any one time while fulfilling other responsibilities.   

Objective: To track care coordination metrics, a nursing scorecard was developed as part of the rollout of nurse-driven care coordination at Community Health Center, Inc. (CHCI), a large multi-site Federally Qualified Health Center and Patient Centered Medical Home.

Methods:  The scorecard is populated with data mined from the electronic health records of all high risk patients in a panel whose care is managed by a nurse and primary care provider.  Data include the number of high risk patients, the number of those enrolled by a nurse in care coordination, length of time patients were enrolled, percentage of recently discharged patients in the panel that were contacted within 48 hours, and percentage of patients with uncontrolled hypertension and diabetes.  The nursing scorecard was built as a collaboration between CHCI Business Intelligence, quality improvement department, and the nurses being scored. Nurses receive their scorecard every two weeks. 

Results: In the first three months of implementation of a new primary care nurse care coordination model, nurses managed about 5% of identified high-risk patients in their panel at any one time.  By six months, some manage up to 19%. At the beginning of care coordination roll out, 22% of patients with diabetes were poorly controlled, and 38% with hypertension were poorly controlled.

Conclusions/discussion:  The dashboard provides a tool that may help in the management of high-risk patients and support the operational oversight of the care coordination process by allowing the health center to set targets and track performance over time.

Learning Areas:

Administer health education strategies, interventions and programs
Chronic disease management and prevention
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs

Learning Objectives:
Describe how a nursing scorecard can track population metrics for individual nurses who provide care coordination to high-risk patients in primary care.

Keyword(s): Chronic Disease Management and Care, Community Health Centers

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: As the CNO for CHCI, Mary Blankson is responsible for advancing the role for nursing within primary care, including aiding in the design, implementation and measurement of the impact of the comprehensive RN care coordination program. Mrs. Blankson works to develop actionable data with proven impact to patients and full acceptance within nursing, in collaboration with CHCI's Business Intelligence and QI teams.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.