Asked about the mission of the Care Transformation and Innovation (CTI) team, Debra Payne, Director of Care Management, references the quadruple aim in healthcare. “Our vision and our efforts are aligned with the quadruple aim,” she explains. “We want to improve the experience of providing care and support the network – physicians and their patients – to ensure positive outcomes.”
For anyone not familiar with the “aims,” it may help to know that originally there were three: (1) improving the care experience for the patient, (2) improving the health of populations and (3) reducing the per capita cost of healthcare. As burnout among physicians and nurses reached critical levels, it became clear that caring for the provider had to be an essential focus of any successful healthcare system. While the first three aims capture the objectives of a network, none of them can be realized without engaged, able providers.
Innovative models to empower primary care
Today, empowering the primary care physician (PCP) takes many forms but typically encompasses improved access to data and actionable insights, along with improved resources, so providers can focus their efforts more fully on a patient’s health and well-being.
“We have two models of care we make available to SWHR network physicians,” Debra points out. “The at-risk model utilizes predictive analytics to identify high-risk patients. The goal of our team is to intervene before these events happen, to partner with the provider and support the patient with a multidisciplinary team. The provider continues to be front and center of all decision making and treatment planning, but SWHR may provide a registered nurse, a social worker, a community health worker, healthcare coordinator and a registered dietitian to assist with the spectrum of needs experienced by medically complex patients.”
If a provider chooses the consultative model, the PCP may choose from three disciplines available to address a specific need. “If a patient is managing a chronic condition well but requires nutritional counseling to improve his or her risk factors, then we can involve the dietitian to help that patient understand the impact of food decisions and create healthy meal plans tailored for that individual. For a different patient, the primary need may be one of transportation, so that’s an area where Care Management can collaborate with the practice and the patient member to improve outcomes.”
“We empower the provider by removing some of the burden of non-clinical care,” expands colleague Jennifer Mayhan, Director of Care Management. “We’re able to provide ‘eyes in the home’ which the providers cannot. We have the time and resources to effect small changes in a patient member’s daily life which can make a big difference in their health. By going into the home, we help educate the patient, improving his or her healthcare literacy so they understand how different behaviors impact their situation both directly and indirectly.”
For patients facing serious health issues, one of the most challenging – and yet rewarding – services can involve bringing loved ones together to discuss end-of-life decisions. “These conversations take time and sensitivity,” explains Jennifer. “For some patients, we’re in a better situation than the provider to answer questions. We can take our time, helping an individual give voice to their values and desires. For advance directives, we like to get the family members involved so a patient has the support of loved ones during these delicate discussions.”
Using data to help inform the best care for patients
Identifying a patient likely to benefit from SWHR intervention blends traditional approaches with healthcare advances provided by technology.
“SWHR analysts and lean six sigma black belts look at data sets from electronic medical records, along with other data sets which have predictive value – such as socioeconomic or geographic factors (Which neighborhoods are food deserts? Which households don’t have vehicles?) – and we partner with data scientists to develop algorithms that will identify these high-risk patients. Before moving forward, of course, we involve the provider who has the personal relationship with that individual to understand their point of view. New patients are coming on or rolling off our service all the time based on a combination of input.”
It’s a process that demands agility – one of the five core values embraced at SWHR. (The other four being accountability, diversity, collaboration and innovation.) “We have “innovation” in the name of our department, but our teams must practice all five values to be effective,” says Debra.
The multidisciplinary approach of CTI Care Management incorporates accountability to each other, as well as to providers and their patients. Embracing diversity is a function of how CTI partners with stakeholders of diverse backgrounds. Naturally, care teams are collaborating and innovating all the time to improve the well-being of individual patients, while keeping an eye on the overarching target of improved population health.
“The practices are SO busy,” says Debra. “We don’t want to add to their administrative burden so how do we adapt? A solution like combining meetings with other SWHR stakeholders to address outstanding topics can be a timesaver for them and for us. Strengthening the relationship demands agility and collaboration from all parties.”
Jennifer agrees. “We’re an advocate for the PCP and we’re an advocate for the patient, utilizing our expertise to adapt treatment plans so everyone wins. Recently, one of our physicians stepped up to engage with us as we were trying to help a patient connect with a nephrologist so she could be placed in dialysis. At the end of the day, it’s about coming together to help the patient.”
Both directors are quick to give recognition to partners throughout the organization. “Care coordination involves all of us at SWHR,” says Jennifer. “For example, we may work with Referral Management to help a member find a pulmonologist. Then our Utilization Management (UM) team is amazing at helping us get the referrals approved so we can move quickly to impact a patient’s health.” She pauses for a moment. “A successful collaboration between Care Management and UM means the provider doesn’t get caught in the middle trying to move a patient through the system. Empowering the PCP, empowering each other, it’s a commitment that impacts every step in a patient’s healthcare journey.”