As busy practices strive to care for patients and meet payers’ requirements, CareAllies’ Value-based Care (VBC) Nurse Team stands as a beacon of support. Our nurses work side-by-side with physicians and their staff to help them improve quality outcomes, including HEDIS and Star measures. (In fact, if you compare the Medicare Star rating of a physician with a CareAllies VBC nurse to one without, you will likely find a difference of 1.0 Star!)
We see ourselves as advocates. Every day, we advocate for patients and the primary care physicians who care for them. We’re dedicated to enabling practices and independent physician associations (IPAs) to deliver the best patient care experience possible. We do that by offering them the reporting, prompting, and organization necessary to address gaps in care and uphold care quality.
What we do: VBC nurses in action
Our VBC nurses work with practices, not for practices. They travel to the practices they work with regularly and communicate with physicians and staff almost daily. While they don’t perform hands-on clinical functions, they do partner with practices to provide them with resources and information. For example, our team can:
- Prepare clinicians for scheduled patient visits. Our VBC nurses routinely review charts to identify patients’ needs before their visits. That way, physicians know what screenings, follow-ups, or other services to discuss.
- Identify unmet needs. Our team helps ensure that nothing is overlooked. After visits, we recheck charts to find any care gaps that still need to be closed.
- Share admit/discharge reports. On a typical morning, most of our VBC nurses send their practices an admit/discharge report so they can better coordinate care and follow-up for patients transitioning into or out of the hospital.
- Engage patients. Our VBC nurses routinely contact patients to encourage them to schedule recommended preventive care, get follow-up services, or otherwise close gaps in care.
- Connect patients with programs and resources. Because our nurses are looking at data and reports that provide important insights, they can recognize high-risk patients and connect them with appropriate disease management programs or refer them to our social determinants of health (SDOH) team. For instance, they might refer a patient struggling with managing their diabetes to a diabetes program, or connect a frequently admitted patient with the SDOH team to help identify and address any social barriers to care.
Simply put: Our VBC nurses have the time, experience, and skills to give practices extra insights and support for their patients. It’s all about being flexible and adapting to the needs of each practice and its unique patient population. We recognize that every practice has its own nuances and is at a different point on the VBC journey. That’s why there is no “cookie-cutter” approach to a VBC nurse’s role.
The difference we make: How VBC nurses add value
The VBC nurse team is not only strengthening the relationship between a practice and its patients, but also between a practice and all the other CareAllies teams—such as the pharmacy, SDOH, respiratory, and other patient support teams. Our nurses may facilitate patient outreach regarding annual wellness visits, train office staff on utilizing various reports, or analyze population health data to identify strategies to close HEDIS, Stars, or other quality measure gaps. Whatever needs to be done, they’re on it!
For example, one of our VBC nurses worked with a physician who had a patient with unspecified abdominal pain. Although the physician requested prior authorization for an abdominal CT scan, the patient’s symptoms continued to get worse. Concerned the patient would have to go to the ER, the physician turned to their VBC nurse for help. She was able to work with other teams to get the CT scan authorized and performed that afternoon—keeping the patient from having to go to the ER.
In another case, a VBC nurse recognized a bone mineral density test was due for a patient who had an upcoming annual wellness visit, so she noted this in the patient’s chart. The physician then ordered the test. Often, the responsibility lands on the patient to follow through, but our VBC nurses know that a little support can go a long way. First, the VBC nurse followed up with the imaging center. When she discovered they did not receive the referral, she asked the office to send it again. Then she followed up again to learn the patient had not scheduled an appointment. After multiple conversations with both the patient and the patient’s son, an appointment still wasn’t scheduled. Instead of giving up, the VBC nurse convinced the patient to provide their availability so she could schedule the appointment on their behalf. The appointment was scheduled, the VBC nurse called the patient’s son to remind him the day before the appointment, and the appointment was completed. Just that little extra human outreach helped the patient understand the importance of the test and got it done.
That’s the kind of work our VBC nurses do every day. They touch countless lives while helping busy physicians ensure their patients are supported throughout their care journeys.
Each VBC nurse caters to their practices’ unique needs, making every day distinct yet impactful. Our team exemplifies versatility and stands ready to do anything to assist their practices and patients. Ultimately, everything we do pivots around one singular goal: helping practices take the best possible care of the people they serve.