Population Health in Crisis: Patient Care Management

Where do nurses and doctors find the time to provide care beyond the office walls? Given the fragmented nature of the U.S. healthcare system, healthcare providers have increasingly implemented Care Management programs aimed at coordinating the care patients receive to improve quality, reduce per capita cost and improve access to care. Traditionally, coordination interventions follow from several perspectives: medical versus social; short-term episodic or acute care versus chronic and long-term care; and various points of access to the patient (e.g., patient targeting to find those in need of high-intensity services, managed care organization, or physician office practice).[i] 

Care Coordinators (a.k.a. Care Managers) provide outreach to at-risk patients to ensure they receive specialized attention related to needed services. They are a key liaison between the patients and their primary care providers. The general intent is to facilitate delivery of the right health care services in the right order, at the right time, and in the right setting.[ii] Recently, care coordination programs have gained a stronghold where managed care organizations, commercial vendors, academic medical centers, and private health insurers sought to implement mechanisms aimed at controlling costs, improving disease outcomes, quality of care, and patient satisfaction.[iii]

At a high level, a 2000 report, entitled, “Best Practices in Coordinated Care,”[iv] made the following five recommendations for Care Management programs:

1. "Programs should follow the three steps: Assess and Plan, Implement and Deliver, and Reassess and Readjust for all enrolled patients;
2. Programs should have express goals of prevention of health problems and crises, and of early problem detection and intervention;
3. Disease-specific programs should incorporate national evidence-based or consensus-based guidelines into their interventions;
4. Care coordinators should be nurses with at least a bachelor's degree in nursing; and
5. Programs should have significant experience in care coordination and should have evidence of having reduced hospital use or total medical costs."[v]

Care Management software comes in various shapes and sizes. Many fill the needs of Clinically Integrated Networks of Hospitals, Clinics, and practices; others come in smaller sizes to meet the needs of small practices. One such package is Stone Health Innovation’s Idea Care. Regardless of the size, certain capabilities should be part of the care management software solution as described below.

Care Coordination Components[vi] should include:

1. The ability to perform a clinical assessment.
2. Develop a Nursing Proactive Plan of Care (POC) separate but approved by the Physician.
3. Identification of participants in the patient’s care and their roles. This also includes those who are not authorized to view or speak to clinicians about the patient’s personal health information (PHI).
4. The ability to communicate to all team members, including patients and their family.
5. Ensure secure information exchange in communications and across care interfaces. Prevention and mitigation of interface issues for transitions and handoffs between settings of care.
6. Provide the ability to monitor and adjust care goals.
7. Evaluate health outcomes – a principle target. Also, identify issues in coordination and care that may impact outcomes.
8. Ensure ability to utilize standard protocols, evidence-based guidelines, self-management programs, and routine reporting and feedback.

Information provided herein serves as development for a working definition that may be a helpful step for others attempting standardization in the area of Care Coordination. Interventions can be demarcated by type that includes not only use of software, but also educational brochures, mailings and member letters, telephonic care management, in-person care management, call centers and self-monitoring devices. Providers may find patient profiling and reports that originate from registries and clinical information systems, electronic medical records, decision support and other electronic communication systems useful. The Agency for Healthcare Quality and Research (AHRQ) published research on care management entitled “Measuring Value in a Care Management Program.“[vii] AHRQ claims that a measurement strategy is critical for determining the value of a Care Management program and to ensure effectiveness in reaching its goals.

 

[i] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 2, Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44011/

[ii] Ibid.

[iii] Ibid.

[iv] Chen A, Brown R, Archibald N, Aliotta S, Fox PD. Best practices in coordinated care. March 22, 2000 [Accessed: January 30, 2006]; Available from: http://www .cms.hhs.gov /DemoProjectsEvalRpts /downloads/CC_Full_Report.pdf. [Reference list]

[v] Ibid.

[vi] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 3, Table 6: Components of Care Coordination. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44012/

[vii] By Using Structure, Process, and Outcome Measures, a State Can Ensure That It Is Receiving a Complete Picture of Its Program's Value., AHRQ. "Section 7: Measuring Value in a Care Management Program." Agency for Healthcare Research & Quality. U.S. HHS: Agency for Healthcare Research and Quality, 2014. Web. 13 Sept. 2016.