UPMC HEALTH PLAN
112 Washington Place, Pittsburgh, PA 15219
Learn more about the UPMC Health Plan.
Sandra McAnallen, MA, BSN, RNSenior Vice President of Clinical Affairs and Quality Performance, UPMC Insurance Services Division
As one of the leading integrated delivery systems in the country, the partnership between physicians and hospitals and UPMC Health Plan has served as a model across the nation for creating a high value network that puts patients and members at the center. By working together, we are able to partner with our network of quality providers to share knowledge, expertise, and technology. We can efficiently coordinate care among doctors and specialists, and can leverage advanced information technology to quickly and securely exchange medical histories, lab results, x-rays, medications, and diagnoses to ensure quality care that is holistic and seamless. Together UPMC and UPMC Health Plan have partnered to provide award-winning health and wellness programs for members of UPMC Health Plan. UPMC Health Plan collaborates closely to develop its programs with the clinical professionals of UPMC. As a result, the knowledge and expertise of physicians, certified diabetes educators, exercise physiologists, certified health education specialists, and leading researchers enrich the programs we offer. As part of the world-class academic medical center that is UPMC, we’re able to offer our members the choice of the top-ranked care and world-renowned innovation of UPMC and high quality community providers. The official term for our partnership is an “integrated deliver and finance system.” In simple terms, that means a partnership to help bring better care, greater affordability, and an improved experience to our members.
Approximately 275 registered nurses and two certified registered nurse practitioners with a broad mix of educational backgrounds are employed by UPMC Health Plan. These nurses serve in a variety of clinical roles within UPMC Health Plan.
Nurses at UPMC Health Plan serve as health coaches to support members in care coordination with their providers. Health coaches provide members with detailed patient education and identify barriers to their care. This is accomplished through motivational interviewing and other behavioral techniques to assist members in self-management mastery and shared decision-making with their providers. Health coaches help members navigate the health care system through multiple providers and link them to community resources. Our nurses are licensed in several states. Health Plan members in all 50 states have access to support from our team.
Care managers interact with members in a number of ways, based on provider referrals or member requests for support. The role of the care manager has evolved to offer more direct contact with members in the provider’s office, in the hospital, and in the member’s home. Face-to-face interactions increase the effectiveness of member education regarding medications, identification of barriers that get in the way of being able to manage chronic illness, and promotion of preventive measures, including lifestyle changes needed to support improved health. As of June 2014, 70 practice-based care managers (PBCM) work in key high-volume primary care provider (PCP) practice sites and serve as direct links between PCPs and members. Community-based care managers are nurses who work with complex and fragile members who need additional support in accessing health care services. These nurses visit members in their homes and may go with them for visits to the PCP or specialist to assist in developing and implementing a plan of care.
Transition coordinators assist with the discharge process for UPMC Health Plan members in selected hospitals by visiting members upon admission, discussing a member’s needs with the nursing staff and attending practitioners, and assisting in discharge planning. Transition coordinators help coordinate the treatment and care for members as they are transferred to the next care setting, including home, a skilled nursing or rehab facility, and/or hospice. Utilization management nurses review physical health and behavioral health inpatient stays and other prior authorized services.
Our nurses also can be found in several area skilled nursing facilities to assist members with smooth transition through recovery from an extended illness or adjustment to living in a long-term care setting. These nurses partner with advanced practice nurses in the skilled nursing facilities to monitor and treat members to reduce their need to return to the hospital setting for minor acute issues, such as urinary tract infections.
Advanced practice nurses also are employed by MyHealth@Work centers that give UPMC employees access to nurses who assist them with acute care needs and preventive health care monitoring, including blood pressure measurement.
Nursing students have a unique opportunity to be exposed to a broader perspective on health care across the continuum with a clinical rotation at UPMC Health Plan. Senior level undergraduate students and master’s and doctoral level students enrolled at the University of Pittsburgh School of Nursing participate in care conferences with the interdisciplinary care team and observe problem solving with an interdisciplinary care approach. Students shadow care managers, social workers, and lifestyle health coaches by listening to their interactions with members and observe and interact with care managers in the community, in provider offices, and in hospitals. Graduate students work on specific projects related to care coordination issues.
In the past year, the UPMC Health Plan Professional Practice Council launched its first quarterly newsletter and promoted continuing education opportunities offering more than 400 hours of continuing education for our nurses.