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
UPMC Health Plan is the second-largest health insurer in western Pennsylvania. As part of an integrated health care delivery system, UPMC Health Plan partners with UPMC and community network providers to improve clinical outcomes and the health of the greater community. Nurses at UPMC Health Plan have a pivotal role in the care coordination process, providing an emphasis on better health through prevention, better quality of care, and cost containment. More than 300 registered nurses and four certified registered nurse practitioners with a broad mix of educational backgrounds are employed by 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.
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. 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. Advanced practice nurses 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.
UPMC Health Plan also is becoming a place where nursing students are exposed to a broader perspective on health care across the continuum. Beginning in the fall of 2012, senior level students enrolled in the Transitions to Leadership course and master’s level students enrolled in the Clinical Nurse Leader program at the University of Pittsburgh School of Nursing have the opportunity for a clinical rotation at UPMC Health Plan. Students meet with senior leaders who share key issues and trends in a number of lecture presentations. Students participate in care conferences with the interdisciplinary care team and observe problem solving with an integrated 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.