Through attentive care, dedicated service and comprehensive guidance, nurse case managers make a tremendous impact on patient outcomes. As an integral part of Vālenz Care, a triple-URAC accredited solution within the complete Vālenz™ ecosystem, Valenz nurse case managers work closely with patients, providers, employers and payers to ensure the right care at the right place and time, paving a more cost-effective path to healthy outcomes.
As we recognize World Health Day on April 7 – and because 2020 has been named the International Year of the Nurse by the World Health Organization – we are celebrating the vital role nurses play in keeping the world healthy. How do nurse case managers accomplish this?
Valenz Care Management Senior Manger Sylvia Robinson, RN, COHN, says their most significant role in today’s healthcare is coordinating and managing patient care. “Care coordination is a collaborative process that involves navigating treatment with physicians, social workers, patient families and other providers, such as home health and physical therapists,” she says. “Ultimately, our goal is aimed at determining the care that plan members need and guiding them on improving health while also minimizing healthcare expenses.”
For patients, nurse case managers are the central point of contact and advocates for high-quality, lower-cost care. For self-insured employers and other professional stakeholders, they help manage health administrative costs and quality by reducing unnecessary and/or preventable emergency room visits, hospitalizations, tests and other high-dollar claim events.
“The Valenz promise is to engage early and often for smarter, better, faster healthcare, and our nurse case managers are essential to that promise,” said Amy Gasbarro, Chief Operating Officer. “Their work improves quality and outcomes while empowering our clients to move from reactive plan models to proactive population health management.”
This level of care and service results in healthier outcomes for all involved. Here are three primary ways our nurse case managers positively impact care quality and healthy outcomes:
Patient Education and Support
By providing continuous, evidence-based guidance and education, nurse case managers fulfill a key responsibility in helping patients and families fully comprehend health conditions and treatment options, so they can stay on the path to better long-term health.
“When patients have greater awareness and understanding of the treatment plan – and when they receive support from nurse case managers – we tend to see a much better likelihood of compliance,” says Valenz Nurse Case Manager Jessica Mangum, RN, OCN, CCM.
Nurse case managers also provide guidance to patients on effectively self-managing chronic conditions, so patients can take charge of their health and be their own catalysts in making positive lifestyle changes.
“A key component of the education process is to also evaluate the patient’s understanding of that education and his or her ability to take action on it,” Robinson says. “That includes setting short-term goals that they can achieve and celebrating those successes with positive feedback.”
Avoiding Unnecessary Costs
While providing comprehensive care that is appropriate for the patient’s needs, nurse case managers strive to minimize out-of-pocket costs.
When our Nurse Utilization Managers are notified of a new diagnosis or treatment recommendation, they conduct a clinical review to determine that the criteria are met for medical necessity and ensure alignment with the most appropriate level of care, according to evidence-based guidelines for that diagnosis. This helps eliminate expenses tied to unnecessary or excessive treatments.
“When we can manage the length of stay and promote case management, we can achieve effective cost containment while providing excellent service to the members and the plan,” says Valenz Nurse Utilization Manager Staci Cunningham, LPN.
In addition, the shift in focus to proactive health management – getting regular medical care before serious illness strikes – enables nurse case managers to help reduce or eliminate the need for costly medications and physician or emergency visits. That’s a benefit for both members and payers.
Navigating the Health System
For many people, the complexities of the healthcare system can feel so overwhelming, they don’t know where to start.
“Some of the biggest challenges patients face in navigating their care is lack of understanding of the healthcare industry,” Robinson says. “The average patient does not grasp how insurance and healthcare work. They often become frustrated and give up, and then they lose trust in anyone in the healthcare field.”
That’s where a nurse case manager comes in: providing guidance and information on what is covered by a patient’s insurance, managing co-pays, controlling out-of-pocket expenses, and accessibility to care, among many other issues.
“Patients need an advocate to get them through this journey,” says Nurse Utilization Manager Nichole Barone, LPN. “We can research insurance plan documents to give patients the clarity they need; help them understand what benefits they are entitled to; determine whether they need pre-certification before treatment; and assist them in securing all those things.”
Also, people with serious diagnoses like cancer may need a wide range of procedures and tests, which can quickly become confusing for a stressed patient. “By tackling these procedures one by one, we ensure the patient gets the proper, necessary care at the correct time,” Barone says. “We support patients by guiding them through the process so they can focus on getting back to the best possible health.”
Celebrating Nurses on World Health Day
As we celebrate World Health Day in 2020, which is also the International Year of the Nurse, the recognition of our nurse case managers and the amazing work they do takes the spotlight – and it is well deserved. We are proud to acknowledge nurses’ contributions on the front lines of patient care all across the globe, and we share our deep appreciation for the critical role they play in keeping people and communities healthy everywhere.
Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at valenzhealth.com. Valenz is backed by Great Point Partners.
About Great Point Partners
Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at www.gppfunds.com.