Running head: CARE MODELS 1

Care Management Models at PeaceHealth

Janet Palmer

Western Washington University

NURS 442 Interdisciplinary Care Coordination

Julie French DNP, RN & Bonnie Blachly MN, RN

CARE MODELS 2

Care management is a department under transition at PeaceHealth St Josephs Medical Center.

They have, in the last year, transitioned from mostly being staffed with social workers to a registered

nurse care management model. This drastic change in operations has left the care management

department simply trying to make the transition between systems smoothly. They are one year from

their change over and are now going through a department restructure to increase staffing. With this in

mind, currently, PeaceHealth does not follow any particular evidence based care management model

but the closest models to how they operate would be the Better Outcomes for Older Adults through

Safe Transitions (BOOST) and the Bridge Program.

BOOST targets patients at high-risk for hospital readmission and provides those patients with

resources. At PeaceHealth, the care managers are doing similar tasks. One of the tools missing from

PeaceHealths program is a stratified risk assessment tool. If they had a tool like that, they may be better

able to identify high-risk patients. Currently, the way this assessment is performed by the care managers

is to look in the patients chart at how frequently the patient has been admitted to the hospital or

utilized the emergency department (ED) in the last 6 months to a year. Those patients who have been

seen by the hospital frequently are then given a closer to look to establish a more appropriate discharge

plan if possible.

The Bridge program looks at similar patient populations. This model uses a tool to assess need

and focuses on older adults who are discharged home with home health. In the transition from the

hospital, it can take time before the first home health visit. In this period, the risk for hospital re-

admission is high. The Bridge Program also looks at caregiver supports of the patients. Caregivers are as

crucial in reducing readmission rates as the patients themselves. Patients with good support systems in

place are often able to receive quality care without hospital readmission.
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PeaceHealth has already had marked improvement in their readmission rates in the quarter

following their switch from a social worker model to an RN care management model of care

coordination. The current structure at PeaceHealth features RNs doing the work of care management in

different sections. There are nurses doing the tasks of discharge planning, of utilization review and care

management in the ED. It also still includes social workers to help with mental health and community

resources and these social workers work closely with the RN care managers. With the restructure and

addition of more staff to the care management department, the goal is to combine these separate roles

into one more cohesive care management plan. The same nurses on the inpatient units who are doing

discharge planning will be able to have fewer patients and focus more of the continuum of care from

admission to discharge rather than focusing only on discharge planning. With the increase in staff and

experience within the role of care manager, perhaps more evidence based care models will be able to

be used in practice.

The current situation in PeaceHealth St Joseph Medical Centers care management department

is one that has not yet been conducive to implementation of a structured care management model. As

changes in structure within the department progress, it is likely that more attention to unification and

optimization of resources will occur. With this, it is probable that evidence based practices and models

will be looked at as a means of improving patient outcomes. The current, informal practice of the RN

care managers most closely resembles a combination of BOOST and the bridge model. In the future,

PeaceHealth needs to adopt a standardized risk assessment tool.