A Day in the Life of Nurse Care Manager Dawn Buckley from the Rhode Island Chronic Care Sustainability Initiative

When South County Internal Medicine joined the Rhode Island Chronic Care Sustainability Initiative (CSI-­RI) in 2010, the practice hired a nurse care manager, Dawn Buckley, RN, who has played a key role facilitating significant transformation inspired by the initiative.

“Our entire practice has changed. We’ve gone from a physician-­centric to team-­ centric model. Our focus on tracking quality measures and setting goals is improving,” stated one physician at the six primary care physician (PCP) practices located in southern Rhode Island. “Physician time is better spent, and patients are better prepared for visits.”

The Day Begins

Each day quickly brings new challenges for Buckley as she works to best meet the needs of her patients and their family caregivers.

At 8:00 a.m., she logs on to her computer and reviews the list of scheduled appointments to identify patients at risk for complications. The practice recently adopted a risk stratification care management tool that classifies patients into four categories, from no risk to high risk, using color codes. Many patients have not yet been coded, so Buckley works to identify patients with the highest risk for complications. Those patients meet with Buckley for a 15-­minute visit before their scheduled PCP visits. She asks questions to understand their situation, reviews medications, and talks with family members and other caregivers. This pre-­visit planning helps the physicians better allocate their time with patients.

Buckley then reviews the daily Admission, Discharge, Transfer (ADT) report that South County Hospital emails to the practice each morning. This report lists all patients from South County Internal Medicine who were admitted, discharged, or transferred from the hospital. Because about 70 percent of the practice’s patients receive care in this hospital, this report contains a gold mine of data to help Buckley identify patients in need of care management. She also checks CurrentCare—Rhode Island’s health information exchange—for ADT activity at other hospitals.

Regardless of their need for care management, all patients discharged from the hospital are contacted within two business days to review medications and discharge orders—an evidence-­based standard adopted by this practice.

She fires off emails to some of the PCPs, sharing information about a recent patient admission. Next, she flags electronic health records to alert physicians who have scheduled office visits today about recent concerns raised by families, caregivers, the Visiting Nurse Services (VNS), and others. She shares her assessments and recommendations regarding some of these concerns with each physician.

The Morning Rush

Patients begin to flow into the practice when the doors open at 9:00 a.m. Buckley starts with several scheduled appointments for “wellness visits” —an annual voluntary checkup for Medicare patients. These patients, often accompanied by their caregivers, bring a completed Health Risk Assessment to the 30-­minute appointment.

During the appointments, Buckley reviews changes to the patients’ medical health, cognitive and functional status, and social history. She then makes referrals to appropriate patient education resources, including Stanford Chronic Disease Self Management Classes that she conducts, and other community resources, such as transportation and social services. Buckley has trained the practice’s two LPNs to also perform these “wellness visits.”

After her early appointments, a physician pulls Buckley into an appointment with a patient who has high cholesterol and needs dietary education. Certified as a cardiovascular outpatient educator by the Rhode Island Department of Health, Buckley provides the patient with immediate counseling.

Next, Buckley meets with a diabetic patient. As a certified diabetic outpatient educator, Buckley helps her diabetic patients understand and manage their condition. At this appointment, the patient brings his glucometer and Buckley downloads and discusses his readings—something that rarely happened before South County Internal Medicine became a PCMH. “We didn’t have time to deal with meters before Dawn came,” one physician notes. Now, more than 100 patients are actively engaged in this aspect of care. Buckley uses motivational interviewing techniques that she learned while taking a Guided Care training offered by CSI-­RI to help the patient set new goals. After the visit, Buckley speaks briefly with the physician to relay the patient’s progress. This information allows the physician to better focus time spent with the patient. Buckley has also trained the front office staff to remind patients during appointment scheduling to bring in their glucometers, blood pressure logs, and complete Health Risk Assessments, if applicable, so patients are better prepared for their appointments.

Before lunch, Buckley pulls reports for each physician showing the number of patients receiving smoking cessation interventions. South County Internal Medicine is eligible for performance payments from all the payers participating in CSI-­RI if the practice meets certain quality targets, including one for tobacco cessation interventions.

The Afternoon Rush

After lunch, Buckley reviews hospital discharge summaries online and begins contacting patients in need of follow-­up. She places a call to a recently discharged patient to assess his physical, mental, and functional status. She then places a call to a patient found to have a very high blood glucose level after recently being admitted to the hospital for cancer. Buckley attempts to track down the patient and schedule a follow-­up appointment with his PCP.

Buckley moves on to send a mass email notifying male diabetics about a “Men’s Night Out”—a chronic disease self-­management class that she is facilitating later in the month. Then she answers a call from the VNS asking her advice about managing a patient at home. She consults with a physician regarding this patient. Because of her licensure as an RN, she is able to take verbal orders from the physician to change the patient’s medications; enter the orders into the chart;; and call the patient, pharmacy, and the VNS about the changed orders. Buckley has developed a strong working relationship with the VNS and keeps them on speed dial as a valuable resource for many of her patients. Next, a physician pulls her into an exam room to counsel a patient and his family. The patient’s health is declining and he has lost 15 pounds since the last visit. “In these moments, patients and families are often the most open to interventions. This opportunity might be lost if the counseling is done days later, over the phone, or by someone not connected with the practice,” says Buckley.

At the end of the day, Buckley meets with the front office staff to help her conduct outreach to a list of patients who have not had a primary care visit in over a year. Buckley will be back tomorrow at 7:30 a.m. to meet with practice staff and PCMH practice transformation experts from the CSI-­RI project. They will discuss how to improve patient satisfaction and establish a patient advisory group. Buckley is responsible for helping the practice maintain its recognition as a PCMH.

It’s been another long day, but Buckley could not imagine a better job. “This is an incredible position and so professionally rewarding. It surpasses my prior experiences working in a hospital,” she says. “The opportunity to develop one-­on-­one relationships with patients, their families, and caregivers has resulted in long-­term, meaningful connections that have led to improved health care.”