Purpose: Comment the Discussion
To Comment
Across the world access to quality healthcare and the cost of said care is a major concern. In the United States escalating costs of healthcare due to chronic diseases has led to a merger of technology and health as it relates to data management (Newhouse, et al., 2011). Working for a health insurance company in a clinical division, most of the patient data that is used to make decisions is delivered through an electronic clinical exchange.
As a health plan, we are contracted with the Agency for Healthcare Administration (AHCA) and therefore, must adhere to very specific criteria related to the management of patient data and expected patient outcomes.
Within our work process we report on information specific to performance benchmarks, clinical dashboards, disease management, quality indicators, evidence-based practices and outcomes(Hamric, Hanson, Tracy, & O'Grady, 2014). In my current role as a Clinical Leader for Medicaid disease management, I review electronic reports related to the above data and feel comfortable in applying the reported information to make decisions about how to engage the patient in their care.
Some examples of the type of information that is collected are high ER utilization, frequent inpatient admissions, compliance with primary care physician (PCP) appointments, medication utilization and compliance, patient access to care complaints, diagnosis and compliance with HEDIS measures.
While, my organization does have accountability for successfully meeting these expectations, as an APRN my personal accountability increases. The direct proximity of the interactions between practitioners and their patients places them in the best position to deliver quality care.
Therefore, practitioners are held most accountable for the discrepancies in the care patients are receiving (Baker & Hopkins, 2010). Practitioners receive the same reports as the health plan regarding patient data. Utilizing the report from the aspect of the provider will be a change for me. Currently, it is frustrating to me when I see patients that have never established with their PCP. However, they are utilizing the ER for all their needs.
The PCP looks to the health plan to make an impact in the patient's utilization because it directly impacts their payment based on their contract. As an NP my focus would not be to look for the health plan to resolve my issue with my patient's non-compliance. I feel that it would be my responsibility as the provider to engage my member by utilizing the patient data that is readily available to me. It is the interpretation of this data by the practitioner and subsequent application that would make the biggest impact in patient outcomes.
References
Baker, L. C., & Hopkins, D. P. (2010). The contribution of health plans and provider organizations to variations in measured plan quality. International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care, 22(3), 210-218.
Hamric, A., Hanson, T., Tracy, C., & O'Grady, E. (2014). Advanced practice nursing: an integrative approach. St Louis, MO: Elsevier.
Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., & Weiner, J. P. (2011). Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economics, 230.