Problem: Florida Community Health Centers (FCHC)’s ability to manage care for patients with multiple chronic conditions is impacted by the number of nursing care phone calls completed, which had recently declined to an average of 200 patient calls per month. This represents only 17% of the patient population in need. FCHC needs to greatly increase the ability to reach out and manage care for more patients.
Root Causes Discovered:
Missing documentation required by Medicare in order to count the call and receive reimbursement
Time wasted searching in the electronic medical record (EMR) for care plan notes
Excessive time and variation in the creation of patient care notes
Care Managers or Care Coordinators don’t always complete the care plan
Educated everyone on the CMS and process requirements
Clarified roles and responsibilities
Removed waste and inefficiencies
Reallocated staff to cover key tasks
Cross-trained staff to use an existing tool within the EMR that enables care providers to easily build personalized care plans, enter real-time updates, and manage care plan meetings
Identified activities for calls in a central area within the EMR
Refined care plan guidelines to be user-friendly and consistent
Results: Increased the calls from 200 a month to 900 a month, supporting more than 80% of the patient population, and reduced the care coordinator’s time in the EMR while generating an additional $30,000 a month in revenue.