The Case for Care Management: Arline’s Story
About 15 years ago, I got a call from a 78-year-old patient named Arline. I was immediately concerned because she was very confused. Despite her age, she had always been mentally astute. When I investigated, it was clear something was seriously wrong. She was staggering and alarmingly disorganized. After a quick analysis, I concluded she had either experienced a neurological event, or she was under the influence of some substance. I asked her if she had consumed any alcohol (rare for her) or taken any medications. She replied “I took my medications like I always do.” When I asked to see her medications, she showed me a large plastic bin that contained dozens of bottles of pills used to treat the chronic conditions she had developed over the years. There were pills of every type and many prescriptions were years old. When I asked her what she had taken, she responded, “A pink one, a yellow one, and two green ones.” Fortunately, the clinical event quickly resolved when I clarified what medications she should actually be on and discarded the rest.
As the Chief Medical Officer of the health system serving Arline, I took it upon myself to better understand how a large, apparently high-quality health system such as ours could allow events like this to happen, and how could it be avoided in the future? My analysis allowed me to begin recognizing the profound challenges facing patients like Arline.
Arline went on to live a fruitful life until she died at 93 years old. Over that time, I learned a great deal about the ability of the U.S. national health system to manage patients with chronic conditions. It was profoundly disappointing how ill equipped our health system was to address Arline’s health needs. Mind you, each individual physician, nurse, and other care provider involved in her care did an excellent job. When Arline visited our clinics, hospital, or ED, we did a great job. But, we still did not meet her needs. How could this happen? In short, Arline needed routine, ongoing care and support and it became very clear our system was not structured to provide it. Gaps in care were common. Too often the right hand did not know what the left was doing. As good as we were, we were simply not organized to support patients like Arline. I suspect most other health systems across the country face the same challenge.
The Need for Care Management Initiatives
Patients with complex healthcare needs like Arline’s account for a high percentage of annual medical expenditures. Facing rapidly rising demands for higher quality and lower costs, every healthcare executive in the country faces the daunting task of revamping the delivery system to demonstrably improve quality, increase care coordination, dramatically lower costs, improve patient satisfaction, engage and empower patients and families in their care, and better manage the health of populations, especially the elderly and those with chronic diseases like Arline. In the emerging value-based health care delivery environment, this will be an imperative.
Leading healthcare organizations across the country are employing the Triple Aim (improving the health of populations, improving the experience of care, and reducing per capita costs of health care) as a framework to transform the delivery of care. Understanding and effectively managing population health is central to each of the Triple Aim’s three elements. Effective care management has emerged as a leading component of managing the health of populations.
Care Management Defined
Care management has been defined in a 2009 article in the New England Journal of Medicine as “a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services.” In short, care management is a range of activities intended to improve patient care and reduce the need for medical services by helping patients and caregivers more effectively manage health conditions.
An effective care management program includes a number of key, interrelated elements:
- The ability to identify patients who could benefit from better care management including the ability to stratify them by risk and need.
- Specially trained care managers with reasonable patient loads (often though not always nurses), working with physicians and other members of the multidisciplinary care team.
- An expanded, more multidisciplinary view of the care team in which we reassess practitioner roles in chronic illness and health including the role of primary care physicians, specialists, care management nurses, ancillary providers, and community resources.
- The ability to communicate effectively among all parties including providers, patients, families, and community resources required to support the patient.
- A focus on outcomes driven by an effective continuous improvement strategy.
- An advanced analytics strategy that integrates key lessons into an EMR allowing the care team to focus on high-risk/high-need patients, effectively inform decision making, and support comprehensive performance improvement initiatives.
- A highly patient-centric approach that educates and engages patients and families.
Improving Care Through Care Management
There is growing evidence that care management can improve the quality of care, although it takes effort, time, and the implementation of new care delivery models and support systems to realize those benefits. Care management’s impact on cost reduction is somewhat less consistent. Programs that effectively manage patient transitions from hospital to clinic to home are the most successful, largely because they reduce hospital admissions or prevent readmissions. Care management centered on primary care models are also being shown to result in savings.
Serving as Arline’s personal care manager and coordinator over the fifteen-year period before she died helped me appreciate the gaps that exist in our current delivery system and the challenges we face as health system leaders. These are gaps that all health system executives must fill and challenges we must address.
Addressing these challenges will necessitate profound changes in how care is delivered and how healthcare providers, patients, and families are organized and supported. This transformation will be complex and definitely not be for the faint of heart, but it will also be profoundly gratifying when achieved. It will produce a health system that will be able to more effectively care for and support patients like Arline who need it most. In the process, we have the potential to create a care delivery system that will be the greatest the world has ever seen–a system that can more effectively manage the health of populations. Over those fifteen years, this became a very personal passion for me because, you see, Arline was my mother.