Nurse Case Managers’ Proposal for Job Duties

We were recently made aware that MHP will be adding an additional position for
a NCM for the Medicaid plan. We met briefly in the hall to discuss assignment
stratification. Currently, the NCMs are stratified according to geographical location of
PCP and number of members assigned to those PCPs. We all believe that this
stratification has worked well over the years. However, as we grow and progress in the
future, we believe that MHP could be better served by the NCMs. We believe that the
new nurse should assimilate into the current stratification system. However, we also
believe that one of the current nurses should then move into a complex case
manager/disease manager role. This proposal will outline the advantages and
disadvantages to implementing a new system to be carried out by the NCMs. We do not
propose that these changes be implemented on a permanent basis. We simply believe that
we should be allowed to try this new system for a period of three months, and then re-
evaluate the effectiveness of this new system.

Advantages

The complex and disease case management programs have been developed as a
requirement of NCQA. However, as we know, frequent contact with our members for
education and assistance in navigating the managed care system also helps us to contain
costs. Kay has shared with me that our complex case management members have
decreased their utilization of the emergency room. I do not have any specific numbers or
percentages to back that up—it would be very interesting to conduct a “study” to help
determine the positive impact that our CCM program has had on our members and our
health plan. At this point in time, we know that our program is not running up to its
potential. That is the main reason we want to affect some changes to help our programs
become more successful. Debbie has pointed out to me on several occasions, that the
proposed assignment changes would simply enhance our overall case management
efforts. This would be achieved by allowing one person to “own” the master diabetic and
asthmatic registries. The “complex nurse” would then be responsible for updating the
registry on a regular basis, and working from that registry. That master registry then can
be divided out by nurse as it is currently. One person could then have a “sole” focus on
truly managing our disease management programs and complex case management
programs. As a result of this increased focus, we should be able to improve our HEDIS
scores with the additional focus on our diabetic and complex members. Additionally, we
have purchased the Jiva software, attended the training sessions and have utilized the
program. Again, we have not utilized the software in the manner it was intended to be
used. We propose that because of the daily responsibilities of each nurse, it is nearly
impossible to get the value that we expect out of this software. We truly feel that there
must be a nurse dedicated to our formal case management efforts.

Disadvantages

There are, of course, disadvantages to any plan, and ours is no different. One
disadvantage is that the individual nurse no longer “owns” everything about the member
as he or she once did. As MHP continues to grow, the question that we think we need to
ask ourselves, is, “can we continue to do the job the same way we always have?” We
believe the answer to be “no,” just as the company grows, so too must the employees.
Secondly, it is somewhat of a disadvantage to have the responsibility of complex and
disease case management resting on one person. First, that person may decide at some
point in time that he or she wishes to terminate his or her employment with MHP. This
leaves MHP in a somewhat vulnerable position. However, when and if the time comes, a
new case management nurse will need to be trained to transition into that role. Also, a
disadvantage is that at the current time, we all are “cross-trained” (meaning that we all
know the different aspects of one-another’s job responsibilities) this will no longer be the
case 100% of the time. However, the nurses will still know the job that we do about 80 %
of the time.

Current Job Description (Summary)

Currently the NCMs are responsible for the following:

 Review and authorization of all services for members

 Utilize knowledge of screening criteria, clinical criteria, amongst others
 Participates in the medical management of members
 Performs as member advocate with emphasis on education and managed care
 Monitors member’s utilization patterns
 Collaborates with medical director and senior management on complex cases and
special projects

In our vision, this would not change, only a part of it would. We would carve out the
complex and disease case management portions. The complex and disease case
management nurse would assume those functions, as well as other responsibilities
commensurate with the position. Other responsibilities could include responsibility of
NCQA measures related to the position, as well as serving as a liaison to the other
NCMs, in regard to NCQA compliance and assistance with case management
functions.

Current CCM Description (Summary)

Currently, the CCM nurse/Team leader is responsible for:

 Integration, coordination and continuity of health care services delivered to our

members.
 Assessment of aberent utilization patterns, presence of multiple diseases,
reinsurance cases, and problematic pharmacy utilization in order to identify
members who would benefit from case management.
 Focuses on pre-assessment in order to proactively manage complex and
catastrophic cases.
 Works collaboratively with medical management staff and senior management on
complex cases, with specific attention to areas such as health and wellness,
 medical and pharmaceutical utilization patterns, discharge planning after inpatient
admission, and coordination of medical and behavioral health needs.
 Coordinates problem solving and develops care plans for complex cases.
 First resource for medical management staff, and responsible for appropriate
NCQA standards and HEDIS rates, and heads various special projects.

From a personal standpoint, I would like to have an opportunity to showcase the skills
and attributes that I have gained while being employed by MHP and pursuing higher
education, in a more concentrated capacity. I believe the disease and complex case
management members (as well as the plan) would be better served by having one person
that is able to truly focus on this specialized role. I am interested and willing to take on
this new system and develop it into something that makes a positive difference for our
members and for MHP. I am highly motivated and excited by this possible opportunity to
increase my knowledge, skills, and interactions with members. Additionally, I would
incorporate an ongoing evaluation of the program’s effectiveness in order to demonstrate
the value that this program and I bring to MHP. Several areas would need to be
addressed: PCP, ER/UC, and medication utilization among other indicators of benefit
utilization. Also, we need to know if our members are healthier because of the
interventions of the case management nurse.