Open Forum

Melissa Taylor, MSN, RN, AMB-BC, NE-BC

Director of Ambulatory Nursing – Primary Care

Elliot Medical Group

Phone: 603-663-3503

Email: mtaylor@elliot-hs.org

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Hello,

If the highest risk patients are about 5% of the attributed population, would that be the sweet spot? Seems low but also working with higher acuity patients can take more time. Or is it the tope 5% you follow for 30 days and make only the initial to the rising risk population with a handoff to care managers if patient could benefit from further self management support? Also, wondering if we pulled a couple nurses together doing the work to get their input. Based on their volumes and what they can get done in a day... it would be interesting for that dialogue to come up with a pilot metric.

Thanks,

Ashley Rosa, MSN, BSN, RN

Manager Ambulatory Care Management

Bronson Healthcare Group, Michigan

Bronson Healthcare – A Forbes Best-In-State Employer (2022-2024)

Hi Tammye,

Could you share more about your TCM nurses? Our TOC volume is so large we would not be able to follow patients for 30-days. Do you follow all patients or have criteria for those your team need to follow?

We set a target for at least 12 calls on average a day. That being said, there are more that go uncalled, and if we followed all the patients, we would have a rolling 240 per nurse a month. I have tried to research caseloads through my years in care management and there are not set protocols or targets that I have been able to clearly find.

I did however find the following:

• Sg2 2016
  • Health Coaches 30-150 panel size for care coordination by RNs (could use staff with other credentials)
  • Contact Center 80-120 panel size for care coordination by RNs

• Advisory Board 2014
  • Finally, Reliant employs Transition Coordinators, medical assistants used to support both the Complex and the Chronic Care Managers. These coordinators are charged with managing all high-risk and rising-risk patient transitions from hospitals, skilled nursing facilities, and rehabilitation centers and facilitating access to social support programs. Transition Coordinators typically manage 300 to 400 discharges per month.

With that, I am also interest in knowing caseloads for both TOC nurses and complex/chronic care management nurses. Thank you!

Ashley Rosa, MSN, BSN, RN

Manager Ambulatory Care Management

Bronson Healthcare Group, Michigan

Bronson Healthcare – A Forbes Best-In-State Employer (2022-2024)

• Patients # of conditions
• Average age
• # of medications
• Behavioral Health Challenge?
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