NJ Nurses Train to Coordinate Their Patients' Care

A new crop of nurses is being trained as population care coordinators -- nurses who serve as part coach, part health advocate to improve coordinated follow-up and preventive and wellness care.

The program is a collaboration among Horizon Healthcare Innovations (HHI) and its education partners Duke University School of Nursing and Rutgers University College of Nursing.

It's attracting nurses like Janet Duni, who has been working for the past year as a population care coordinator at Vanguard Medical Group in Verona.

"I manage the most high-risk population in the practice," she said, those with chronic conditions like diabetes and heart disease. "I reach out to patients who have had a hospital discharge or an emergency room visit, to make sure that they are at home, that they are settled, that their medications are correct. If they need a follow-up appointment with a doctor, I make it."

Duni, with 30 years experience as a nurse, including in the emergency room and intensive care, began the new 12-week training course in January, a combination of online and face-to face-instruction that focuses on case management using databases, skills Duni will use for the care she coordinates for 5,000 Vanguard patients who are Horizon members.

The training is funded by HHI, a new company launched in 2010 by Horizon Blue Cross and Blue Shield of New Jersey. "We are creating a new nursing leadership role that will support New Jersey's primary care doctors and deliver improved care to patients," said Christy Bell, chief executive of HHI.

Dr. Richard Popiel, president of HHI, said the company has been funding the hiring of population care coordinators since launching a patient-centered medical home pilot program more than a year ago with eight primary-care practices. That pilot was expanded with an additional 15 practices in January, and now involves about 80,000 patients. The curriculum to train more coordinators grew out of the work that has already begun in the medical practices.

"This gives us a great opportunity to formalize the education around what they are going to be doing in these practices," Popiel said. "This is something nurses have not been taught in traditional nursing schools."

At a press conference Wednesday at the Rutgers School of Nursing in Newark, Popiel said HHI is investing more than $1 million to train 200 nurses over the next two years. The nurses will work in medical practices that are partnering with HHI, which is both paying the cost of training the nurses, and providing additional payments to the medical practices so they can afford to hire the nurses.

At the Vanguard Medical Group, Duni said she spends a lot of time on patient engagement. "I try to make sure that patients understand that they are part of their own healthcare team and they are engaged in keeping themselves healthy."

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