The Expanding Concept and Role of Care Management: Coordinating Care for Carlos

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role-of-care-managementCarlos is a 68-year-old man with insulin dependent diabetes, hypertension, and osteoarthritis in his knees which makes it difficult for him to exercise. Although he speaks some English, his primary language is Spanish. He often has to ask his non-Spanish speaking care providers to explain health-related terms and they have a hard time understanding his heavy accent. He runs a small, neighborhood Mexican restaurant, works long hours to make ends meet, and has no fixed routine for meals or exercise—although he has unlimited access to food choices at the restaurant that are not particularly conducive to good diabetes management or weight control. His primary care physician is worried because Carlos has not been particularly compliant with his diet and medication regiment, and his blood sugar and HgA1c have been under poor control. He also has visited the ED recently with hypo- and hyperglycemic episodes.

The Role of Care Management Today

Patients like Carlos and Arline (read her story here), show why there is a growing focus on population health and care management. Anyone involved in healthcare could argue that we have been doing care management for decades with increasingly good results. And, that person would be right. There is overwhelming evidence indicating that patients with serious illnesses and injuries are experiencing better outcomes and living longer. Whether one looks at stroke, heart attack, trauma, or cancer, survival rates are improving and patients are benefiting from better care.

In the face of rising concerns about quality and costs, the focus on effective care management has grown even more intense as a leading component of managing the health of populations. If we have historically always focused on managing care, what is different now?

The Definition and Scope of Care Management Today

The issue here is one of definition and scope. Historically, managing care referred to managing care effectively during patient encounters in the clinic, ED, and hospital. Due to growing quality and cost concerns, the definition and scope of care management is broadening to encompass the care of populations and managing care across the continuum.

In the modern era, an article from Bodenheimer and Berry-Millett in The New England Journal of Medicine defines care management more broadly 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.” While other definitions have been proposed (such as one by the Center for Healthcare Strategies), they all more or less offer the same basic concepts. Let’s review why this new, more broad definition is important and what it implies for patients like Carlos.

Using Care Management to Address Problems in Patient Care

Our current system of care delivery is overly fragmented and generally characterized by communication failures, gaps in care, and duplicative or non-beneficial healthcare tests and services. This results in uneven quality, inconsistent outcomes, an unacceptable risk of error, and rising costs in terms of both healthcare resource consumption and human suffering. Resolving these issues requires us to move toward a delivery system that can provide more comprehensive, seamless and effective care management across the continuum.

This is particularly important with elderly and/or chronically ill patients like Carlos and Arline, who spend the majority of their time living outside of traditional care environments. The concept of a care environment is expanding to include a patient’s home and place of work. Health services need to be better aligned, coordinated, and managed to serve patients and the people and institutions that interact with patients whenever and wherever care needs to occur. To adequately manage population health, care management must occur across the continuum.

The Role of Care Management: Coordinated Care Across the Continuum

This implies that care will be more consistent and better coordinated. Cross continuum care coordination is a key element of modern care management. According to the Agency for Health Research and Quality (AHRQ), care coordination implies that health systems will purposely “organize patient care activities and share information among all of the participants concerned with a patient’s care” – including community support services, patients and families. It further suggests that there will be advance knowledge of the patient’s needs and preferences, that information will be effectively communicated whenever appropriate “to the right people, and that this information will be used to deliver safe, appropriate, and effective care to the patient.” Ultimately, care gaps and redundant care should be eliminated, outcomes should improve, and value maximized.

So, how did this broader definition of care management benefit Carlos? Robert, a nurse care manager, had Carlos as a member of his 200 patient panel. Robert was well aware of Carlos based on meetings with his primary care physician and the fact that Carlos had recently been flagged in the EMR as a patient with a growing risk of needing expensive inpatient services. Robert’s job is to coordinate available support services to make sure Carlos remains healthy.

Robert began meeting with Carlos every two weeks, interspersed with periodic phone calls. All interactions, instructions, and written materials were in Spanish. Carlos was educated about his diabetes and the importance of blood sugar control, diet, exercise and weight loss. Robert improved medication compliance by providing Carlos a week-long, pre-filled medication box. The care team taught Carlos methods of exercise his knees would tolerate. A dietician helped Carlos understand how he could use certain foods already available in his restaurant to be more compliant with managing his diabetes. Daily food and medication logs helped him stay on track. Throughout this period of time, Carlos’s primary care physician directed the effort and the entire care team monitored interventions and his progress.

With each passing week, Carlos became more informed, enthusiastic and engaged with his “equipo de atención” (care team). He became more compliant with medications and diet, dropped ten pounds, and his blood sugar and HgA1c fell to acceptable levels. In short, Carlos felt better, was more compliant, under better clinical control, and became healthier. As a result, it became less likely that he would require more expensive and intense healthcare interventions. Carlos continues to meet with Robert on a much-reduced basis to reinforce and/or improve his ability to self-manage his diabetes.

Carlos is a beneficiary of the expanding concept and role of care management.

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