Value of Nurse Care Coordinators in Chronic Care Management

Nurse care coordinators in chronic care management positions can reduce healthcare costs and manage patient healthcare service utilization. Chronic care nurse coordinators work in various healthcare settings, such as hospitals, insurance companies, medical offices, long-term and catastrophic care, workers’ compensation, and home-based care.

As part of care teams for hospital discharge and home-based care, nurse care coordinators review medical charts, educate patients about health conditions, coordinate equipment and medical supply needs, manage prior authorizations and referrals for specialty care, and provide other support to ensure members receive cost-effective care.

The motivation of most nurse care coordinators is straightforward—to make a difference in the lives of patients.

Patients credit care coordinators for their support and compassion, helping them navigate complicated situations.

“Jane is the bright spot in my life on my darkest days. When I was having difficulty recovering from a recent hospitalization, she made sure that my medical supplies showed up on time and explained how to use them. I don’t know what I’d do without her.” 

The Behind-the-Scenes Life of Care Coordinators

Nurse care coordinators operate in high-stress and time-sensitive situations. Patients experience health events that result in hospitalizations or multiple illnesses, resulting in a change of condition necessitating immediate attention.

With daily activities documented for billing, interactions like long telephone hold times or a lack of follow-up from others can exceed justifiable time guidelines. A 40-hour work week can quickly turn into late nights or weekends to meet performance goals.

The ability to shift priorities and triage situations is necessary. As a result, accessing time-saving resources is critical for nurse care coordinators to optimize efficiency. Healthcare technology platforms for care management, whole-person care, closed-loop referrals, and ordering home medical equipment can offer time-saving measures.

The Prevalence of Chronic Disease

Research confirms that chronic disease is a growing concern in the United States across all age groups.

• According to the CDC, 47% of persons over 55 have two or more chronic health conditions. (1)
• One in three American adults, four in five Medicare beneficiaries, and a growing number of children have multiple chronic conditions. (2)

Hospitalizations, Hospital Discharges, and Chronic Disease Data

In 2007, hospitalization rates for near-elderly (persons 55 to 64) were similar on a percentage basis to younger hospitalized adults (45-54) and 65- to 74-year-olds at 17.1%, according to the Healthcare Cost and Utilization Project (H-CUP). (3)

Hospital discharge rates were also similar on a percentage basis.

45-54           55-64         65-74

In 2019, data from H-CUP confirmed the three most common comorbidities— a secondary diagnosis that differs from the reason for the hospitalization—for inpatient stays. (4)

These include hypertension (53.2 percent), diabetes (26.4 percent), and chronic respiratory lung disease (20.5 percent), which result in longer and more costly hospital stays.

Who Are the Patients Supported by Chronic Care Management Nurse Coordinators?

Meet John, a 66-year-old physically disabled male diagnosed with hepatitis C, cardiovascular disease (that required placement of an artificial heart valve), somatic symptom disorder, COPD, seizure disorder, anxiety, depression, paranoia, and PTSD.

He is dually eligible for Medicare and Medicaid and is one example of a patient with multiple chronic diseases who benefits from individualized chronic care coordination.

As a young child, he experienced adverse childhood events (ACES) due to parental abuse, which contributed to his chronic health conditions. Physically weak and low in weight, he hesitates to eat foods believed to be contaminated by pesticides or metals.

John uses a walker, an oxygen concentrator, a portable oxygen unit, and a home INR testing device to minimize visits to the doctor’s office, which are emotionally stressful and physically draining. He self-isolates and rarely leaves his home. While he has siblings, they find his behaviors difficult. They remain in phone contact and visit when necessary.

Additionally, John has a high I.Q. and is suspicious of and resistant to care—resulting in chart notes of being “non-compliant” and a “difficult patient.” Doctor appointments are challenging due to his perseveration in reliving stories about traumatic health events rather than focusing on immediate needs.

He has sent Medicaid home health aides home in tears due to his behaviors. He refuses counseling, mental health support, and taking medications deemed unnecessary.

Over the past two years, John has established a trusted relationship with his nurse care coordinator, Mary. She coordinates his medical care with providers, completes chart reviews, provides chronic disease education, manages prescriptions, and reorders medical equipment and supplies.

Due to concerns about his health and high anxiety levels, John tends to call 911 for emotional support. While he has had one to two hospital stays in the past two years, contact with Mary has been instrumental in reducing unnecessary emergency room visits.

Like many nurse care coordinators, Mary’s compassion and empathy for John’s emotional and physical care needs result in success in managing care and effective use of services.

Medicare, Medicaid, and Dual Eligibles

Nationally, 12.5 million persons are jointly enrolled in Medicare and Medicaid. These beneficiaries are known as dual eligibles. They receive their primary health insurance coverage through Medicare, a federal program, and assistance from state Medicaid programs. (5)

Similar to John, dual-eligible individuals are among the most frail and sick, resulting in high costs for Medicare and Medicaid programs.

• Dual eligibles represent 17% of the Medicare population, translating to 33% of Medicare costs and 14% of the Medicaid population, equating to 32% of total Medicaid costs.
• Almost four in ten (37%) of dual eligibles are younger than 65 and qualify due to a long-term disability. (6)
• More than half, 51%, are people of color.

In 2008, coastal states like California, New York, and Texas had the highest level of dual eligibles, 20% or more, as a percent of the total Medicare population by state.

Current demographic trends may continue to drive these numbers higher, supporting the need for care coordination efforts and managing utilization.

Sources:

(1) Percent of U.S. Adults 55 and Over with Chronic Conditions. CDC National Center for Health Statistics. https://www.cdc.gov/nchs/health_policy/adult_chronic_conditions.htm

(2) Bierman, Arlene S. et al. Transforming Care for People with Multiple Chronic Conditions: Agency for Healthcare Research and Quality’s Research Agenda. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8515222/

(3) Russo, Allison, et al. Hospital Utilization Among Near-Elderly Adults, Ages 55 to 64 Years, 2007. Statistical Brief #79. NIH National Library of Medicine: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK53968/

(4) Owens, et. al., Comorbidities Associated with Adult Inpatient Stays, 1029. H-CUP Statistical Brief #303, December 2022.  https://hcup-us.ahrq.gov/reports/statbriefs/sb303-Comorbidities-Adult-Hospitalizations-2019.jsp?_gl=1*1xcy62p*_ga*MjEwMjg3MzU5NC4xNzE5NDU1NTEw*_ga_1NPT56LE7J*MTcxOTQ1NTUwOS4xLjAuMTcxOTQ1NTUwOS4wLjAuMA..

(5) Pena, Maria T. et al. A Profile of Medicare-Medicaid Enrollees (Dual Eligibles) Kaiser Family Foundation, January 31, 2023. https://www.kff.org/medicare/issue-brief/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/

(6) Dual Eligibles Across the States. Data Brief Series No 12: The Scan Foundation. February 2011. https://www.thescanfoundation.org/sites/default/files/1pg_databrief_no12.pdf

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