• Bringing Care Management Into the Community

    Chris Anderson Mar 21, 2016

    Healthcare organizations can expand care management programs by finding viable partners in the community and improving patients' ability to manage their own care.

    Last month, Physician Business Adviser examined the benefits to healthcare organizations of care management programs that target specific patient populations, along with some of the organizational and technology underpinnings needed to run an effective program.

    In addition to building those capabilities, healthcare leaders increasingly recognize the importance of reaching beyond the acute care episode or primary care physician’s office visit and into the greater community. The point is to deliver care where the patient lives and works and also to develop methods to better manage the social determinants of health, such as people’s economic stability, living environment, and social support systems.

    In short, in addition to data collection and analysis and the development of systems to coordinate care across the healthcare continuum, effective care management programs entail developing methods to reach out to—and provide care for—patients beyond the walls of a healthcare facility.

    “Part of the shift in work flow today is also a philosophical shift in how we think about what a patient needs,” says Vanessa Pratomo, MD, MPH, medical director for ACO quality improvement and chronic illness management at Montefiore Health System, Bronx, N.Y. “Physicians tend to be trained to problem-solve based on what a patient is complaining of. This is a bit of a shift to think about other factors that aren’t health-related, but can impact health down the line.”

    Getting a Handle on Social Factors

    The increasing prevalence of shared-risk payment models means healthcare providers must have a broader view of a patient’s health and wellness. In many cases, care management programs might be getting only a portion of the way there.

    “We are not quite hitting the mark yet because, oftentimes, we focus on coordinating care for patients across the continuum of health care and stop there,” says Trissa Torres, MD, senior vice president, Institute for Healthcare Improvement. “We don’t get to that piece where we also reach out to address what else may be going on, those social determinants of health.”

    To start, physician leaders and care teams should develop a solid understanding of how the community in which their patients live may affect their day-to-day lives. Issues such as housing, education, and transportation can present barriers to care—but also offer opportunities for providers to help.

    “At Montefiore, we have a fairly large population with high rates of diabetes, obesity and asthma, among other chronic illnesses,” Pratomo says. While hospitals and care teams might see this need and immediately look to develop specific treatment programs for this population, another option is to tap community resources. To that end, physicians and their care teams should have extensive knowledge of the resources that are available.

    “For example, if you are located in a community that has a very active diabetes prevention program, you may leverage it by referring patients to that program,” Pratomo says. “That would be a benefit to that program, to your patients, and to your organization, and is something that is already there.”

    This is exactly the approach Torres advises. In her experience, when healthcare organizations begin to understand how social determinants such as a lack of dependable transportation may present barriers to segments of the patient population, their first instinct is to take on the problem themselves. “This is where organizations tend to do things that lead them astray,” she says.

    As an example, organizations might say to themselves, “‘We will become a transportation organization,’ when what’s needed is to partner with others who can help provide or solve the transportation issues,” Torres says. “Often this can result in partnerships that have never occurred to the organizations before.”  

    Torres points to loneliness as a common social determinant among elderly populations, one that can trigger mental health issues and, in turn, affect medication adherence, exercise, and diet. In such cases, health providers may find that local church groups have active programs to regularly visit with seniors who live alone. “We don’t have to do it. We don’t have to pay for it,” Torres says. “We just need to know that resource is there, partner with them, and help make sure that they are successful because that also helps us be successful.”

    Delivering Care in the Community

    While healthcare organizations are reimagining how—and with whom—to partner in the local community, they also can develop methods to directly provide care and guidance to patients outside their walls.

    “Providers, in general, are still pretty focused on the face-to-face visit,” says David Wennberg, MD, former CEO of Northern New England Accountable Care Collaborative and currently the chief science officer of New York-based Quartet Health.

    As Wennberg sees it, an opportunity exists to foster greater engagement of patients in their own care. For instance, people may find it inconvenient to leave work in the middle of the day to visit their physician. Instead, providing the necessary information or care recommendations via text, email, or over the phone in the evening can be just as effective, help reduce physician workload, and reinforce care self-management among patients.

    This approach also requires helping patients develop the confidence and the mindset to actively manage their own care. “That whole idea of engagement—of making patients a part of the team and not coming to the doctor as the expert, but making them the expert at managing their own care—is really important in getting the patient to be self-managed,” Wennberg says. “This is best done through a combination of efforts including education of the clinical staff, supporting them with communication media such as videos and online materials, and, most importantly, expanding the team to include people with experience in health coaching and shared decision making.” 

    Pratomo believes this form of engagement is a core component of effective care management and population health management programs.

    “When I think about care management programs, I think about how important it is to meet patients where they are,” she says. “Most of the time, patients aren’t in the doctor’s office, but there are lot of things a patient might need in between visits. So trying to address patients’ needs in between the office visits and providing them with those services in a timely manner is key.”


    Chris Anderson is a freelance writer and editor who covers payers, new care models, healthcare IT, and precision medicine.

    Interviewed for this article: Vanessa Pratomo, MD, medical director for ACO quality improvement and chronic illness management, Montefiore Health System, Bronx, N.Y.; Trissa Torres, MD, senior vice president, Institute for Healthcare Improvement, Cambridge, Mass.; David Wennberg, chief science officer, Quartet Health.

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