2015 PCPCC Fall Conference

Panel: Community Coordination Can Improve Chronic Care Management

November 20, 2015 11:03 am Michael Laff Washington, D.C. –

Jeromie Ballreich learned the value of coordinated care all too early, when as a college student, he suffered a severe spinal cord injury while swimming and nearly drowned.

Panelist Jeromie Ballreich, who relies on coordinated care after suffering a severe spinal cord injury, discusses the value of community-based organizations during the Patient-Centered Primary Care Collaborative Fall Conference.

Ballreich spoke about coordinating care for chronic illnesses between clinics and community-based organizations as part of a panel discussion at the Patient-Centered Primary Care Collaborative Fall Conference, held here Nov. 11-13. Panelists called for a number of changes to improve how this care is delivered, including better transportation for patients, bringing outside caregivers to office visits and, crucially, making sure physicians are paid for their work.

Ballreich explained that he needed regular physical therapy sessions and, eventually, vocational therapy after he moved from the hospital where he was treated for six months to his family's rural Pennsylvania home.

As a patient with quadriplegia, Ballreich depended on his mother as his primary caregiver, but he required true coordinated care to live the way he wanted. Although his community offered many of the health services he needed, those services were not connected in a manner that was convenient for patients.

Story Highlights
  • Panelists at the Patient-Centered Primary Care Collaborative Fall Conference suggested several changes that could improve chronic care coordination with community-based organizations.
  • Helping patients get to the services they need and including more caregivers in office visits would help, said a patient on the panel.
  • It is crucial, panelists said, that insurance companies be willing to pay for improvements.

"I was fortunate that my primary care physician took a personal interest in me," said Ballreich, confiding that he had dated the physician's daughter in high school. "He made house calls when necessary."

Now living in an apartment in Baltimore, where he is pursuing a Ph.D. in heath economics at Johns Hopkins University, he has adjusted to his condition and settled into a comfortable routine. But he still needs help getting the chronic care he requires.

It's a challenge simply to navigate the maze of services. A key change that would help, said Ballreich, would be better integration of home health care workers into the care network. Specifically, it would be helpful if they were more visible members of the health team and could take part in office visits.

"They are not nurses or doctors, but they are in charge of your medical needs," he said.

Transportation also should be considered part of coordinated care, especially in rural areas, said Ballreich. He often relied on a ride-sharing program.

Telehealth systems could help alleviate transportation issues if reimbursement policies changed. For instance, Ballreich said he would like to be able to ask his physician to view an uploaded photo and tell him whether he might have an infected pressure ulcer that required a visit, but he can't because the physician is paid only for office visits.

Another way to coordinate care, said Tricia Jefferson, director of healthy living and strategic partnerships at the YMCA of Delaware, is to incorporate preventive care away from medical settings.

For example, a program in Delaware that coaches individuals at high risk for diabetes to lose weight and exercise more encourages attendance by meeting in libraries, churches or community centers -- away from anyplace that resembles a medical setting.

"How many people like to go to the hospital?" Jefferson asked. "People want to go where they feel comfortable."

Retention rates are 90 percent, said Jefferson, and the program costs about $430 a year. But insurance companies will not pay for it.

"That's very affordable compared to the cost of treating someone who is diagnosed with diabetes," Jefferson pointed out.

The Delaware program contributes to coordinated care by including patients' participation and attendance records in an electronic health system.

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