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Care Management Links the Pieces

By Dr. David C. Pate, News and Community
September 26, 2013

Care management is a critical component of accountable care.  It is optimized when there is a foundation of a single electronic health record for patients, which St. Luke’s has been implementing.

It includes care coordination, such as our CoPartner efforts, our heart failure and new Metabolic Syndrome Clinic, and our Diabetes Education and Management in conjunction with St. Luke’s Humphreys Diabetes Center. And it includes management of care transitions when a patient is discharged from the hospital to a rehabilitation or skilled nursing facility. 

It is care providers coming together to coordinate the care of patients, especially those with chronic illnesses. One of our board members describes this evolution in the care model by using the analogy of individual cowboys compared with a pit crew. Care management results in better care at a lower cost, and patients love it. 

Here you’ll find a report on our care management initiative by Chereen Langrill, our communications coordinator for SELECT Medical Network. It’s part of a continuing series of Thursday posts on specific SELECT initiatives to provide clinically integrated care.

Think about every component and participant in health care, including, but not limited to, primary care providers, pharmacies, insurance providers, and dozens of specially trained clinicians at hospitals and in many other care settings.

Now think about how those components and participants might connect when you need care. This is the concept behind care management.

Care management can be thought of as a branch of a larger tree known as population health management. Dr. Pate recently talked about population health management in a blog post about metabolic syndrome, and plans to write more on this important aspect of our work going forward. Population health management describes our ability to help at-risk and high-risk patients take better control of their health conditions by removing as many risk factors as possible.

Why is it important?

Proper care management is vital for health care to be successful. When people come to the hospital or visit a provider to receive treatment for a medical condition, they trust us to make decisions that will impact their health.

Often these decisions require many layers of support that cannot, and should not, stop with the provider.

For example, a triage care manager is responsible for mining data and identifying the needs of a population to ensure their needs are being met through various programs throughout the system. These programs may include CoPartner, medical and post-acute care management, wellness, and various outpatient programs that St.Luke’s Health System has developed.

Identifying a program that will support patients is the first step. The next step is to determine how physicians and their staff can use the program in a team-based way to care for these patients. Incorporating an entire team is the essence of care management and offers patients the best chance for success.

What’s the challenge?

People with complex care needs require significantly more time from a care management perspective. These people might need help with care after being discharged from the hospital because they live alone and don’t have friends or family who can care for them. Those without resources such as friends and family are also more vulnerable when facing critical health challenges such as dementia. Without a proxy in place to make decisions on their behalf, such people may even spend additional time in the hospital, if only because they have nowhere else to go.

These are costly cases. Insurance might not cover those prolonged hospital visits. A person with complex medical needs may also pay a high price physically, because this population is more vulnerable than others. Without advocates who can help manage their care, people in this category are at risk for taking improper doses of medication, or not returning for follow-up appointments because they don’t have transportation. Someone with a diagnosis such as metabolic syndrome is at greater risk for diabetes and other serious conditions if they don’t learn how to manage those risk factors, and they have a greater chance for success if there is a team available to teach them necessary skills.

What’s the goal?

Better communication among providers and better patient experiences are primary goals associated with this initiative, which clearly connects with the Triple Aim of better health, better care, and lower cost. Care management revolves around the patient experience.

How will it make a difference for patients? What changes will they see?

People with complex care needs will see a greater wealth of resources and support. The initiative will work with providers throughout SELECT to increase and improve patient care.

Planned changes include the implementation of care managers at hospitals, clinics, and practices throughout the network.

What are the next steps?

Many levels of support will be created to further this initiative. This could include patient registries, new services, and patient care programs.

Care management will evolve along with the healthcare model. As our business model moves from fee for service to one that is value-based, we will have greater opportunities for non-traditional approaches to care. Because of that, this initiative is an ongoing process, rather than one with a finite beginning and end.

What’s the measure of success?

Quality and value measures are being developed as part of this initiative, and those metrics will be reported in order to standardize the way care management is applied across the continuum of care.  Those metrics will be viewed through dashboard technology to make it easier to monitor our measures as we move forward.

Editor’s note: This is the sixth installment of a 10-part series introducing clinical integration initiatives that St. Luke’s is involved in.

Clinical integration is a term used to describe health care providers working together in an interdependent and mutually accountable fashion to pool infrastructure and resources. By working together, providers develop, implement and monitor protocols, “best practices,’ and various other organized processes that enable them to furnish higher quality care more efficiently than could be achieved working independently.

St. Luke’s Health System is a participating provider in the SELECT Medical Network of Idaho, Inc. SELECT is a network of healthcare providers in southwest Idaho that is focused on a coordinated model of care delivery focused on providing enhanced quality and better value to individuals, employers, and insurers.  

In keeping with the clinical integration effort, 10 initiatives were developed for 2013 to help establish the standards of enhanced quality meant to help create a new vision for health care.

The initiatives are:

  • Diabetes
  • Tobacco treatment
  • Back program
  • Advance directives
  • Patient-centeredness
  • Care management
  • Medicine reconciliation
  • Hand hygiene
  • Pharmacy optimization
  • Shared analytics

About The Author

David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.