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The Extraordinary Value of Chronic Care Management As Seen Through The Lens Of The Patient

Posted on November 28, 2018 I Written By

The following is a guest blog post by Spencer Kubo MD, Chief Medical Officer at CareCognitics.

The concept of adding chronic care management (CCM) to primary care practices is appealing on many different levels, but implementation has been sporadic.  The dismal uptake is multifactorial and is largely based on the perception that the value (return) may not be worth the investment.  However, Wendi Capers, Practice Manager of Priority Health Group, a primary care practice in Las Vegas, Nevada, recently relayed to me three patient stories that are guaranteed to change your perspective.  This group was an early adopter of CCM and is using Cariatrix as their CCM provider.

Patient #1 is an 82-year-old male veteran who was becoming increasingly isolated, lonely and depressed after the death of his dog.  The patient did not have any family or friends.  He had no physical complaints that would have necessitated a call to his doctor and did not feel he had any reasons to request an appointment.  The Care Ally from Cariatrix noticed that the patient was not responding to the regular emails and texts that give reminders about upcoming preventative health measures. She called the patient and astutely picked up on the feelings of isolation. After their conversation, she found a program that could provide animal therapy for vets.  She also located a community center that held classes in Tai Chi, one of the patient’s favorite forms of exercise.  The patient is responding well to these interventions and has “turned around.”  Now the patient promptly responds to the emails/texts, and even calls the Care Ally every month just to check in, clear signs of greater engagement and well-being.

Patient #2 is a 62-year-old male with diabetes that was not well controlled, as evinced by a baseline A1C that was elevated to 11.9.  When asked about the suboptimal A1C result, the patient was taken aback, saying, “I can take care of myself.”  Again, this patient did not see the need to contact his doctor.  But the CCM team slowly won him over through multiple contacts.  The Care Ally then observed during medication reconciliation that there were extended periods between refills of his insulin and oral medications.  The patient at first did not acknowledge this gap, but then finally admitted that the co-pay had forced him to delay refills. He remarked, “I can eat and heat my home, or I can get my meds, but I can’t do both.”  The Care Ally was able to petition the manufacturers for hardship papers, and now there is no gap in prescription refills.  Most importantly, his A1C has been reduced to 7.9!

Patient #3 is an 83-year-old male who has a cognitive impairment.  After an annual wellness visit, the primary physician ordered home health care visits to help with the patient’s weakness and general limitations.  However, the patient became increasingly disoriented and refused to let the home health aide into the home, thinking she was a photographer.   As in the other cases, this patient was not responding to the regularly scheduled emails and texts that are standard components of CCM.  However, the Care Ally received an automated alert, read about his refusal to admit the home health aide in the EMR, and then called the patient directly.  The Care Ally immediately recognized the patient’s disorientation and called the police department to do a well check on the patient.  The police found the patient to be obviously confused and called an ambulance to take the patient to the hospital for an emergent evaluation.

You will notice some common themes in these patient stories.  The first is that the CCM program had established a digital two-way communication platform with the patient.  This is a game changer from the traditional paradigm of medical interaction, which is dependent upon the patient calling the office to report a problem.  None of these patients felt they had any reason to call the doctor’s office (in that they were unable to recognize that they were in need of any care). However, the lack of responses to email and texts served as an indicator to the Care Ally that something might be amiss. In the traditional paradigm, corrective actions are initiated only AFTER the patient contacts the doctor about a problem.  In the new CCM paradigm, there is outbound communication that can help detect problems even if the patient is not contacting the clinic.

Second, the CCM program could provide VIP services that truly made a difference in patient outcomes–these are simple yet extraordinarily effective.  One problem with the term “VIP Services” is that many think of limousines, suite upgrades and free meals.  But here we see that “VIP Services” can be low cost but directed interventions to resolve specific issues facing a patient.  Most clinical practices do not have the resources to contact patients who are not complaining, and most do not have the resources to respond to the cases above in the same proactive fashion that CCM allows.  A CCM program can truly provide that competitive edge and get medical practices paid for the effort!

Third, these examples point to the synergistic effects of technology and the human touch.  Technology is an answer because it can help us monitor patients for signals and provide additional communication channels.  But we need the human touch in many cases to really make the difference.  As a practicing cardiologist, I get excited about how much technology can help, but at the same time, I am humbled by how much technology still cannot do. It is the balance of technology and human touch that will be a game changer in healthcare.

Finally, it is important to assess the value of CCM in terms of revenue, improvement in quality scores and other hard metrics.  But there is a “softer” side to the value equation that makes CCM valuable and helpful to patient outcomes.  These stories from the “trenches” of CCM providers happen all the time–they form a compelling testament to the value of CCM!

About Spencer Kubo, MD
Spencer brings a diverse set of experiences and expertise to the chronic care management strategies of CareCognitics. Previously, he was Medical Director of the Heart Failure-Heart Transplantation Program of the University of Minnesota, where he authored over 250 original articles and abstracts. He has also been Chief Medical Officer or a consultant to numerous medical device companies developing breakthrough treatments to improve the lives of patients with cardiac diseases. He maintains a part time clinical practice and most recently was the Physician Lead of the Heart Failure Service Line for Allina Health. In that capacity, he leads a multidisciplinary group focused on improving outcomes of heart failure patients treated at any of the 12 hospitals and over 90 clinics in the Allina system.

Note: John Lynn, Founder of Healthcare Scene, is an advisor to CareCognitics.

Patient Confidence in Chronic Care Management

Posted on August 1, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Managing chronic patients is an extremely important part of our healthcare system. Not only is there now a chronic care management code but it’s widely known that chronic patients make up a huge portion of healthcare costs. The more we can do to manage chronic patients more effectively, the better it will be for patients and healthcare costs.

The problem is that West recently did a survey which illustrates that we still have a long way to go in helping patients feel comfortable with how their chronic conditions are being treated and managing chronic patients.

Here are just a few of the stats from the West survey:

You can download West’s full Strengthening Chronic Care survey results if you want to see more details.

The most disturbing stat in the above graphic to me is that 59% of patients with a chronic illness do not feel they are doing everything they can to manage their condition. On the one hand, you could suggest that all of these people are just hoping that there’s more they could do to manage their illness, but really there isn’t anything more. However, I don’t think that’s very likely. I think it’s more likely that we could do more to better help manage patients’ chronic conditions.

One of the most exciting things about technology to me is that it can connect the chronic patient with the healthcare system in between office visits. That’s a powerful idea that we really haven’t capitalized on the way we should in healthcare. As we move to chronic care management and value based reimbursement, healthcare organizations are going to have no choice but to figure this out.

Working on Value Based Care and Fee For Service at the Same Time

Posted on November 2, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While at MGMA I had a chance to sit down with Mike Hofmeister, Vice President of Value-Based & Community Solutions at Allscripts, to talk about Allscripts’ Chronic Care Management (CCM) and other value based care efforts. Coming out of MGMA I’d say that Chronic Care Management (CCM) was one of the biggest topics people were talking about.

What’s a bit unique about CCM is that it’s a hybrid of value based care in a fee for service world. In fact, when I asked Mike about how Allscripts was balancing value based care with fee for service he told me that they were looking at opportunities to implement processes, procedures, and workflows that benefited both value based care and fee for service.

I found this to be an incredible insight into the path forward for those of us trying to figure out how to navigate this new value based reimbursement world. No doubt there are plenty of efforts that can satisfy both sides of the equation. The reality is that we can’t just flip the value based care switch on and the fee for service switch off. We’re going to be living in a hybrid reimbursement world for a long time to come.

Mike also told me about how Allscripts was well positioned to help with doctor’s CCM efforts because at the core of the CCM program is access to healthcare data, analytics capabilities, and call center capabilities to follow up with the patients. Sure, there are a few more details to the program, but Mike is right that CCM requires the right healthcare data, data processing, and the right patient follow up procedures. For many patients a phone call is still the best follow up procedure. Although, I’m still interested to see how quickly this switches over to secure text from phone calls.

What seems clear to me is that most provider organizations aren’t going to take part in CCM on their own. A few larger ones will try it, but most provider organizations will be looking to an outside company to help them participate in the CCM program together with a larger group of providers.

Of course, we also have to realize that CCM is just the start. The companies that deliver great CCM solutions will be well positioned to deliver on future value based care programs. They’ll just want to make sure that they balance their value based care work together with the ongoing fee for service world.

Chronic Care Management Infographic

Posted on October 13, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Smartlink Mobile Systems has put out an infographic that looks at interest in the chronic care management program by physicians. This data is quite interesting since the chronic care management program has been one of the popular topics at the MGMA annual conference this week. There’s a lot of discussion about the program and a lot of organizations trying to work out how to do the program effectively. I think that’s illustrated in the graphic below.
Chronic Care Management Infographic

What do you think of the Chronic Care Management program? Are you participating? Are you planning to participate? I’m sure we’ll be writing a lot more about this in the future.