Advanced Care Management: Healing the Whole Patient
The era when success was measured by the number of patients treated by an individual clinician is coming to an end. In its place is a system that defines success as consistently delivering excellent, value-based care, and improving patient outcomes, long-term. In this new world it will take a cross-functional team, following the principles of advanced care management (ACM), to make the vision of value-based care a reality.
A Patient Is More than Their Illness
The concept of delivering ACM to patients isn’t new. Health plans have provided disease management services for members for years. These services would typically be offered to patients with severe chronic conditions such as chronic obstructive pulmonary disease (COPD), heart failure (HF), or diabetes. The care manager’s goal was to encourage patients to follow their prescribed care plan.
While the approach worked in some cases, unfortunately it failed to account for factors in a patient’s life, outside of their illness, that impact the successful implementation of a plan of care. Studies show mental, behavioral, and socioeconomic issues often have a bigger influence on patient outcomes than any individual provider or plan of care.
For example, an elderly HF patient may be willing to follow a plan of care that calls for her to take 12 prescription medications. However, if she doesn’t have transportation to the pharmacy or a support system to pick up the medications, she won’t be able to follow the regimen.
In another instance, a patient suffering from depression may be unable to follow his physical therapy plan following knee replacement surgery. In each case, there is a high likelihood these patients will end up needing further, expensive care.
A Change of Approach
Uncoordinated care can be very costly. A study by the National Centers for Biotechnology Information recommended hospitals focus cost-saving strategies on addressing the inefficiencies created by uncoordinated care. An estimated $240 billion in savings could be recognized from optimizing care coordination. Initiatives such as disease management and patient education are becoming more important given the aging population and the increasing numbers of individuals diagnosed with multiple chronic conditions.
These outside, non-clinical influences must be considered and addressed as part of the overall plan of care. ACM enables such a change by providing a better way to identify and manage high-cost, high-risk, and highly complex patients—and address the factors inhibiting a successful outcome.
Acknowledging the needs of the entire patient, as opposed to only focusing on the specific condition, can have a profound effect in achieving a successful outcome. In a shared risk arrangement, everyone benefits, most importantly the patient.
The Advanced Care Management Team
Many patients are dealing with mental or behavioral issues such as depression, Alzheimer’s disease, alcoholism, or recreational drug use. In addition, socioeconomic issues such as lack of access to transportation or unemployment can hinder the successful implementation of a care plan.
Addressing each of these issues in isolation will do little to improve the patient’s overall health. Changing a care plan may lead to improvement in one area, but have a negative impact on the patient elsewhere.
To achieve success an entire team working together and coordinating their efforts is critical. An ACM team, all of whom are focused on the entire patient, includes physicians, nurses, social workers, pharmacists, psychiatrists or psychologists, and community resources who can arrange things such as transportation or meal delivery.
The Primary Care Physician (PCP) is at the center of the team, particularly in the patient-centered medical home (PCMH) model that is often a cornerstone of shared risk arrangements. Ideally, the PCP is addressing the medical issues while building a relationship of trust with the patient. The ACM program enables other team members to manage additional aspects of patient care. The PCP acts as the coach, ensuring the proper resources are available to the patient. The PCP also makes adjustments to the care plan as needed.
A Relationship of Trust and Understanding
Building a genuine and trusting relationship between the patient and care team is the cornerstone of ACM programs. Often this relationship is built by going to a patient’s home to ask if she’s filling her prescriptions and taking her medications.
It can even be as simple as sitting on the couch and petting her dog during a conversation. As care managers build that relationship they can ask questions and discover what motivates patients to act a certain way.
Here’s an example. An elderly woman whose care plan called for her to walk a specific distance each day suddenly stopped her daily walks. During a visit with the patient, the care team member discovered the woman was embarrassed to be seen in public because her hair was messy. The solution? Purchasing a wig for the patient, enabling her to feel more comfortable in public and reengage in her recovery plan.
Financial concerns can also be a factor, especially for patients with high-deductible insurance plans. Lack of resources may lead to delays in scheduling a test or surgery.
The ACM process enables the identification of these external factors. It empowers the patient and the care team to determine the best path forward to restore the entire patient to full health.
Leverage Existing Infrastructure
Coordinating resources across the care spectrum isn’t easy and implementing new, sometimes expensive, technology may not be the answer. The necessary infrastructure may already exist. It just isn’t being used that way.
One of the best examples is the secure messaging infrastructure that resulted from providers’ ability to securely send a Summary of Care Document or Continuity of Care Document (CCD) in accordance with Meaningful Use Stage 2 requirements. This piece of technology can also be used by care management teams to communicate about things happening with patients.
Keys to Success
An effective ACM approach must address the following issues to ensure success.
As former Surgeon General C. Everett Koop said, “Drugs don’t work in patients who don’t take them.” The same can be said for care plans—they can’t work if they aren’t implemented.
ACM teams can employ behavior modification techniques to motivate patients to make them active participants in their recovery. Clinicians must have an understanding of the patient’s care expectations and keep them at the forefront throughout the care management process. A COPD patient might have the goal of walking his daughter down the aisle at her wedding without an oxygen tank or an arthritis patient may want to return to the golf course.
Bringing Data to Real Life
Using data to tell a story that is relatable to the patient can also provoke change. It’s one thing to tell a patient that statistics show she will only live four to six more years if she continues to smoke. It may be more impactful for a grandmother to understand that if she doesn’t stop smoking, she may not see her grandchildren graduate from high school.
The High Cost of Healing
The high cost of a patient’s medication can also inhibit a successful outcome. Including a pharmacist on the ACM team, who is more aware of pharmaceutical company incentive programs or generic alternatives, can assist the patient in significantly reducing the costs of their prescriptions.
Going Beyond Traditional Providers
Initially, ACM programs have been focused on the sickest five percent of patients–those who are consuming nearly half of healthcare resources. In an “at-risk” model, these patients are most likely to cause a financial loss due to adverse outcomes. New programs, however, are helping drive a higher quality of care at a lower cost across a broader population of patients.
The Allina Health Care Guides program uses outgoing, non-clinical individuals to mentor patients with a similar cultural background who have chronic (but non-acute) conditions such as diabetes. The health system was able to demonstrate a 30.1 percent reduction in unmet health goals (versus a 12.6 percent reduction for those without care guides), resulting in significant cost reductions.
A second program, Peers for Progress, connects patients who are struggling with their illnesses with others who have had the same experience and are managing it successfully.
A newly-diagnosed diabetic is connected with a volunteer who has been living with diabetes for several years in order for the new patient to learn how to manage the condition effectively. Employing non-medical professionals to provide peer support is proving highly effective in improving health outcomes all over the world.
A Catalyst for Change
Focusing on healing the whole patient, successfully improving the quality of care, and reducing costs are the goals of an ACM program. Just as helping a patient feel better inspires her to continue treatment, a successful ACM strategy can inspire the care team to drive long-term, tangible change, leading to improved outcomes for the organization and the patient.