Section 2.

4 Plan

CCC Program Staffing Models

This tool is designed to assist community and health care leadership determine the type and
level of staffing required for care coordination functions to be performed within a community-
based care coordination (CCC) program.

Time needed: 2 hours

Suggested other tools: Population Risk Stratification and Patient Cohort Identification; Resource
Checklist for CCC; Matrix of Care Coordination Related Activities and Staff Roles

Table of Contents
Background on Community-Based Care Coordination Staffing .................................................... 2
Primary Factors Influencing Patient Load for Care Coordinators in a CCC Program ................... 4
Other Factors Influencing Patient Load .......................................................................................... 4
Staffing Level Examples ................................................................................................................. 5
Additional Resources ...................................................................................................................... 6

How to Use
1. Understand that there is currently not a significant amount of experience with CCC staffing
models.
2. Review the staffing models in this tool to determine the type of model to implement that is
most likely to be effective for the CCC program being established.
3. Consider a flexible approach to initial staffing for the program. Monitor the selected model
as patients are brought into the program and experience is gained in what works best for the
number of patients and types of services provided. Modify the staffing model as needed.

Section 2.4 Plan–CCC Program Staffing Models - 1

 Background on Community-Based Care Coordination Staffing
Community-Based care coordination (CCC) ‒ in which patients are engaged after a
hospitalization for ongoing medication management, symptom recognition and management,
and self-care for chronic conditions ‒ is a relatively new function within the health care system.
Where it does exist, the function is implemented in various forms and settings, and a variety of
types of services are being provided over different durations of time. Therefore, different types
of staffing models support different types of programs.
Initially, care coordination was considered the responsibility of primary care physicians, who
would follow their patients intensively post-discharge. In providing reimbursement for such
care coordination, Medicare recognizes physicians or qualified practitioners performing
transitional care management (TCM) per specified CPT codes. As a result, many programs
considered it important to use only physicians or other qualified clinicians, such as advanced
practice nurses or physician assistants, to provide care coordination services.
As the accountable care organization (ACO) model of value-based purchasing emerged,
however, the proportion of “care coordination” as compared to “direct care” and the duration of
such services moving from within 30 days post-discharge to a potential ongoing relationship
with patients quickly led some care coordination programs to consider the need for other types
of clinical professionals, including registered nurses and medical social workers, to provide the
care coordination services, or to supplement qualified practitioners with other staff who can
provide more of the administrative coordination needs.
The following table serves to differentiate between various functions that involve care
coordination:

Provider-based Case Management

Provider-based
/ Care
Type Enhanced Care Transitions Community-Based Care
Management /
of Care Discharge Management Coordination (CCC)
Disease
Planning (TCM) Management
Goal Hospital works Hospitals and Health plans work Team of coordinated
to reduce primary care to ensure care resources improve the
preventable re- providers work to needs are met to quality of life and
hospitalizations improve quality and reduce overall cost satisfaction, and reduce
and ED visits contain costs of care hospital readmissions
and costs for patients
General Process Telephone- Complex Telephone Complex pre-discharge
delivered follow- assessment of delivered follow-up assessment of patient
up with patient patient needs in with patient to needs to develop
to promote hospital followed up encourage ongoing plan of care and
patient safety by telephone and medication taking patient action plan; follow
(including in-person visit(s) and follow-up visits up by telephone and in-
medication with PCP with PCP to reduce person visit(s); ongoing
taking and overall cost of care advocacy, education, and
follow-up communication to ensure
physician visits) fulfillment of plan of care
and patient
satisfaction

Section 2.4 Plan–CCC Program Staffing Models - 2

Types of Patients All patients Patients with Patients with Patients with complex
discharged from complex conditions targeted conditions and/or chronic conditions
hospital at high risk for (often in a value-based
costly care services purchasing initiative)
Typical Duration 2 to 14 days Hospitalization to Quarterly to annual Pre-discharge and
post-discharge 30 days post- for duration of ongoing
discharge condition
General Tasks  Patient  Clinical needs  Patient tracking  Clinical and social
tracking assessment  Telephoning on needs assessment
 Telephoning through chart medications and through chart review,
on review, provider follow- telephone- and in-
medications, telephone- and up person visits
provider in-person visits  Managing logistics to
follow-up and  Communication meet clinical and social
red flags with providers to needs
 Referrals to ensure plan of  Coordination among
TCM or CCC care is in place providers and
community resources
Staff Qualifications  Registered  Registered nurse  Registered nurse  Physician or other
nurse or or or qualified practitioner
 Social worker  Medical social  Social worker (as defined by
or worker Medicare for purposes
 Allied health of reimbursement)
professional and
 Registered nurse,
social worker, and/or
allied health
professional
and/or
 Administrative assistant

Note: Table was compiled from multiple sources

Section 2.4 Plan–CCC Program Staffing Models - 3

Primary Factors Influencing Patient Load for Care Coordinators in a CCC
Program
The patient population to be served heavily influences the patient load for care coordinators in a
CCC program. The patient cohort(s) to be included in the CCC program needs to be defined
early in the program planning phase, and may be determined to be:
 All patients in a given health care catchment area
 All Medicare patients
 All Medicare, Medicaid, and other safety net patients
 Portion of patients in a given health care catchment area based on risk stratification
 All high-risk patients with a certain chronic condition or multiple conditions
 Other (define your
population):_______________________________________________

Other Factors Influencing Patient Load

Once the population of patients to be served, the nature of the CCC tasks and duration of service
provision, and qualifications of available staff (from the table above) are determined, there are
some additional factors to be considered that may influence how many patients a care
coordinator in a CCC program can manage and what, if any, additional resources are needed.
Some of these factors include:
 Distances to be traveled
For example, if there are many high-risk patients in a geographically large, rural community
– travel time becomes an important factor. Strategies can be developed to reduce such travel
time, such as having the care coordinator see patients before or after a planned provider
office visit or by using other means of staying in touch with the patient, such as through
home monitoring or telehealth.
 Risk level of patients served
Risk stratification should consider not only the nature of the clinical condition of the patients
but social needs as well. For example, patients with special language, literacy, financial, and
other social challenges will need more time and coordination than patients without such
challenges but with the same level of clinical risk.
 Available technology resources
If a community has sophisticated registry functionality that enables easy patient, provider,
and community resource referrals and tracking, a care coordinator may not need as much
administrative support.
 Maturity of the CCC program
A CCC program just starting out requires development of provider and community resource
relationships. Similarly, patient trust needs cultivating. New workflows and processes will
need to be developed and refined over time. A care coordinator in a new CCC program will
very likely be involved in all of these aspects, even when there are additional staffing

Section 2.4 Plan–CCC Program Staffing Models - 4

 resources to recruit providers, community resources and patients, and to do the non-patient-
facing administrative tasks such as making appointments and tracking test results.

Staffing Level Examples

The following examples of care coordination staffing requirements are taken from a presentation
delivered at Aging In America (2011) by Schraeder, Volland, and Golden, entitled “Promising
Models of Care Coordination for Beneficiaries with Chronic Illnesses.”
 1 registered nurse per 50-60 patients based in a primary care practice working with 3-5
physicians
 1 advanced practice nurse and 1 social worker per 100-125 patients in collaboration with
a primary care provider and a geriatric interdisciplinary team led by a geriatrician
 1 registered nurse care coordinator per 350-500 patients in a large primary care clinic
with multiple care coordinators

A review of contemporary health care literature on care coordination, combined with

collective experience in current CCC programs, suggests the following recommendation for
consideration:

In general, 1.0 FTE care coordinator in a community-based care coordination

program should be able to conduct 1200 in-office patient visits per year (five patient
visits per workday). The average patient may have between three and six interactions
per year with the care coordinator, with some patients declining such services and
others, depending on their self-management interests and/or current health risk status,
requiring considerably more interactions. Therefore, one care coordinator should plan
to work with a population of approximately 300-400 chronically ill or high-risk
patients. (See Resource Checklist for CCC.)

Section 2.4 Plan–CCC Program Staffing Models - 5

 Additional Resources
Although some of the following references are focused more on care management or case
management than community-based care coordination, each provides greater specificity in task
delineation, percent of time spent on various tasks, availability of certification programs, and
evaluation tools.
 Anderson, St. Hilaire, and Flinter (May 31, 2012). “Primary Care Nursing Role and Care
Coordination: An Observational Study of Nursing Work in a Community Health Center” The
Online Journal of Issues in Nursing Vol. 17, No 2, Manuscript 3. Available at:
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl
eofContents/Vol-17-2012/No2-May-2012/Primary-Care-Nursing-Role-and-Care-
Coordination.html
 Case Management Caseload Concept Paper: Proceedings of the Caseload Work Group, Case
Management Society of America National Association of Social Workers, October 30, 2008.
Available at:
https://www.socialworkers.org/practice/aging/Caseload%20Concept%20Paper%20final.pdf
 Policy Brief: Implementing Care Coordination in the Patient Protection and Affordable Care
Act, Prepared by the National Coalition on Care Coordination (N3C). Available at:
http://www.nyam.org/social-work-leadership-institute/docs/publications/N3C-Implementing-
Care-Coordination.pdf
 American Nurses Association. The Value of Nursing Care Coordination, A White Paper of
the American Nurses Association, June 2012. Available at:
http://www.nursingworld.org/carecoordinationwhitepaper
 Preferred Practices and Performance Measures for Measuring and Reporting Care
Coordination (2010). A Consensus Report, National Quality Forum. Available at:
http://www.qualityforum.org/Publications/2010/10/Preferred_Practices_and_Performance_M
easures_for_Measuring_and_Reporting_Care_Coordination.aspx
 Social Work Leadership Institute of The New York Academy of Medicine, Who is Qualified
to Coordinate Care? Social Work Leadership Institute. Available at:
http://www.nyam.org/social-work-leadership-institute/docs/publications/Recommendations-
on-the-Qualified-Care-Coordinator-FINAL-9-10-09.pdf
 National Association of Professional Geriatric Care Managers, Certification. Available at:
http://www.caremanager.org/join-us/certification/

Copyright © 2014 Stratis Health and KHA REACH. Updated 12/30/2014

Section 2.4 Plan–CCC Program Staffing Models - 6