Nurse Care Managers Bring a Personal Touch to BJC Accountable Care Organization Patients

Phone contact and community partnerships bring help to patients in their homes

by Karen Stewart


Natalie Linton

Pat was happy to be home after a hospital stay, but was faced with a “now what?” feeling.

She was sent home with instructions to give herself daily injections of medication, but was feeling anxious because she hadn’t been able practice while in the hospital. She was also trying to sort through all of the medications she had been prescribed. Home care had been ordered but wouldn’t be there until the next day.

Pat might have been headed for an emergency department visit that evening, if not for the help of a care manager who was assigned to her case through the BJC Accountable Care Organization (ACO).

Medicare patients of BJC Medical Group doctors can choose to participate in the free service. Care managers call and manage patients after they’re discharged from the hospital, or when they’ve been identified as being at a high risk of hospital admission due to chronic disease.

In Pat’s case, Joan Pitkin, RN, called her shortly after she arrived home from the hospital. “I went over how to give herself an injection and discussed her medications with her. She hadn’t noticed a section of her discharge instructions labeled ‘stop taking these medications’ and might have continued with her current medicines and had a bad reaction. When we were finished talking, she felt safer and less anxious.” 


Megan Guinn

The nine nurses, three health coaches and one social worker who are part of the program keep the patient’s physician updated through the patient’s electronic medical record. They assist with coordinating discharges from the hospital, provide information to patients to help manage their conditions, go over instructions and answer questions. 

The nurses help the patient coordinate care with other health care providers and avoid duplicate or unnecessary tests. 

In order to better work with physicians, the care managers will be assigned to particular BJC Medical Group practices and regions, starting in mid-September. “Right now, a doctor could potentially work with up to five care managers regarding their patients,” says Megan Guinn, RN, BSN, care coordination manager. “This is an opportunity for improvement that will align the care managers with the BJC Medical Group regional approach. 

It assists in building a care manager/provider relationship to help facilitate trust and provide integrated care.”

Pharmacy Program Brings Medication Management to the Home
The care managers find that medication issues are often a barrier to better care for their patients. As a result, Gateway Apothecary/Beverly Hills Pharmacy recently entered into a pilot program with BJC ACO. 

“When looking at our patients who have hospital readmissions, we find many have had problems with medications,” says Natalie Linton, RMA, health coach. “We are working on reducing barriers to taking medications properly by taking advantage of services the pharmacy already offers, such as free medication delivery to the home and different packaging options.” 

Pill bottles are the most common packaging method, but strip packaging is offered as an alternative. In strip packaging, when the medication leaves the pharmacy, it has already been placed in dose packs and chronological order. Each individual dose package includes the required prescription information and a pill description for simple identification. It reduces errors for patients with multiple pills to take, and communication can be customized for the patient. 

Free deliveries are made to all of St. Louis city, county, and part of St. Charles and Jefferson counties, and Fed-Ex delivery is offered to areas covered by hospitals and service organizations outside of the St. Louis metropolitan area. The pharmacy calls the patient two days after delivery and again 27 days later to see if the patient is ready for a refill, and offers a visit by a medication coach.

“This is just one additional service offered to patients and their families that helps us focus on and individualize patient care,” Guinn says. 

Opening Doors to Care 
In another partnership, the BJC ACO care managers work jointly with the Community Health Access Program (CHAP). CHAP was started two years ago at Christian Hospital to reroute patients not requiring emergency care away from the emergency department to more appropriate care. Advanced practice paramedics treat patients in their homes and help them find the resources they need to live healthier lives. 

When accountable care patients of the two ACO physicians participating in the pilot program are identified as frequent users of an emergency department, they are referred into CHAP. 

“We find there are social needs,” says Linton. “Social needs impact the patient’s day-to-day living and overall health. 

In addressing and assisting with the social needs, we are also able to assist patients to reach their health needs and goals.”

In Linda Parks’ case, the program proved to be a lifesaver. Parks had been a frequent hospital patient due to dehydration caused by health problems. Once she enrolled, paramedics from the CHAP program visited her daily, administering IVs for rehydration therapy, monitoring her blood pressure and providing education that worked to keep her out of the hospital. During one visit, however, Parks became unresponsive. Through the paramedic’s quick work, she was rushed to Christian Hospital, where she was diagnosed as having a stroke.

“I don’t know what I would have done, had she not been here,” says Parks. “She might have saved my life.” 

Parks says the program has other benefits as well. “It has kept me out of the hospital and treated me at home, saving me money. They have helped to arrange doctor appointments and transportation to get me there. This is a much-needed program to help people like myself and countless others who need a little extra care — just not another hospital stay.”

Advanced paramedics assess patients in their homes based on instructions from their doctors. They also go over their medications and assess the home. For example, they might determine the patient needs a rail in the shower that the paramedics can assist in obtaining through grants. They report their findings to both the primary care physician and the ACO care manager assigned to the case, with the goal of graduating the patient from the program in 12 weeks or when the patient is doing well independently. 

“Most important to me is that the paramedics have been able to reach my doctor about my medical problems, such as changing medication doses,” says Charles Toland. “And they were able to get answers immediately.”

Once patients graduate from the CHAP program, the assigned ACO care manager will call at one week, two weeks and one month post graduation to make sure they continue to do well. The patient also has the care manager’s number, so he or she can call if needed. 

“Patients are very grateful for our help,” says Linton. “The advanced practice paramedics are caring and compassionate. The patients love them. It’s important to us that our patients know we care.”

“It helps to know there are people who care about you as a patient,” says Toland. 

And Guinn agrees. “We are there for the patient. Through the ACO and our partnerships with support programs, we are able to offer an alternative approach to care that assists patients in reaching their health needs and goals while focusing on accessing appropriate levels of care.”

What is BJC Accountable Care Organization?
In 2012, BJC became the first health care provider in the St. Louis area to take on the challenge of forming an accountable care organization to take better care of seniors. 

“We believe we have the ‘world’s best medicine’ — and this makes it better,” says Sandra Van Trease, BJC group president and president of BJC Accountable Care Organization (ACO). “We believe that by working together with our patients in a new way, we can help them get and stay healthier.”

This happened, in part, through improved care coordination and disease management for Medicare patients.

BJC Accountable Care Organization includes all BJC hospitals, BJC Home Care Services and BJC Medical Group. Its focus is to achieve improved patient-centered health outcomes and cost savings by improving care coordination and disease coordination for patients; expanding evidence-based care delivery models; and developing a structure that provides sharing of cost savings, if any, to ACO participating physicians. 

Patients are given the opportunity to become a part of BJC ACO when their physician joins. To date, almost 39,000 seniors are covered by the program. 

The benefit to the patient from this expanded focus on care coordination comes from the ability of the patient and his or her physician to sit down and have a conversation about the care needs of that patient. This results in a care plan that the patient and physician develop together, which addresses the needs of the patient related to his or her health status. 

“At least once a year patients meet with their physicians and spend time going over every aspect of their care,” says Doug Pogue, MD, ACO medical director. “This results in a flow of information that goes to every single doctor and other clinician involved with the patient’s care and allows everyone to be on the same page as the primary care physician.”

Pogue says there are benefits for specialists as well. “When patients come into their office they haven’t seen in awhile, there is a care plan from the primary care physician that shows not only who is involved in the patient’s care, but exactly what’s going on. It allows the specialist to know his or her role in the care and to whom to communicate the results.”
Patient health information shared by Medicare is shared in a safe and confidential way and provides a more complete picture of the patient’s health to improve the patient’s care.