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Wednesday Jun 29, 2016

Clinical Case Managers Improve Chronic Care Outcomes

Every primary care physician is familiar with the complex challenges involved with comprehensive health care delivery. The task can seem particularly daunting when facing communication barriers or when treating the underserved, the disabled and the elderly. Because of this, there is a great need for third-party facilitation through care coordinators, case managers, social workers and lay medical workers.

I first experienced this when I was a resident in the South Bronx. I was intrigued by the benefit of utilizing community health workers as physician extenders who reached out to their communities through patient education and coordination, both in the clinic or hospital and in patients' homes. Now a family physician in my third year of practice, I find great value in care coordinators who facilitate and streamline transitions of care between inpatient and outpatient settings. In our medical home, I frequently use licensed clinical social workers to provide counseling and patient education in smoking cessation, weight management, chronic pain, illness and addiction recovery.  

We also have added a clinical caseworker for chronic care management to ensure optimal communication and continuity of care with our Medicare patients. This service has closed gaps in communication and maximized educational opportunities that might have been missed in the past. Chronic care management also provides a significant opportunity for improvements in medication reconciliation, care coordination, patient retention and appointment follow-through.

Despite these benefits, two main limitations prevent some Medicare patients from taking advantage of chronic care management. One is the challenge of communicating to the patient the benefits of having access to a clinical case manager. The other is the added expense incurred by the patient. Even though the cost is minimal, many patients on fixed incomes view it as an obstacle. It's important to note that when patients have supplemental insurance, we are able to reassure them that the copay likely will be covered and they usually are more willing to sign up.

Despite these barriers, I have had many patients agree to the service, and they have found it to be quite beneficial.  

I had one patient in particular who was completely unclear about the appropriate use of his medications. He had the misconception that he could take all his medications according to his own sliding scale. His reasoning was that he was concerned about side effects and the risk of becoming dependent. This patient had insulin-dependent type 2 diabetes, as well as hypertension, hyperlipidemia and testosterone deficiency, all of which was clearly out of control by the time my case manager reached him.  

Through a collaborative approach, patient education and consistent reinforcement, we were able to rein him in and get him to the point where the medications listed in his medical record actually matched what he was taking. He was proof that the more eyes on the chart and the more communication with the patient, the better.

After seeing successes like this from a physician's point of view, I wanted to hear more from others who make this physician-led collaboration work in my practice. Here's my interview with clinical case manager Cindy Cody, R.N., who joined the program when it began in 2015. It has been edited for clarity.

Q: What do you like most about this position?
A: Helping people to feel better about themselves and to realize that they are only human. So often, while working with patients to lose some weight or lower A1c levels, we can get so focused on the number and think they failed if they are not seeing big results. But it really changes your perspective when you talk with the patient and learn that they cut down from drinking five sodas a week to three or started eating a salad for a meal, etc. Little changes deserve to be recognized and can add up to the big results. That recognition often helps provide the additional motivation they need to make further changes.

Q: What do you like least about this position?
A: The chronic care management program is paid for by Medicare, but sadly it often leaves a copayment for patients. Most of these patients are either disabled or elderly and living on a fixed income. This copayment is the reason many patients do not enroll in the program.

Q: What works really well about this service?  
A: Helping to ensure all is being done for patients to improve their health and develop positive outcomes. I also find patients will be more forthcoming in a phone call in their own home environment than in conversations during an actual office visit. Patients often tell me things during these phone calls that they might be reluctant to say in the office. I also love how it's a check for these patients between visits. I have ladies in their 90s who really need that additional personal call each month to check in on their safety and health status. With these patients, I often work to help decrease fall risks and injuries. These patients then have an open line to call their clinical case manager directly during the day, where they can talk to someone they know if they have a question or problem. Many like having that security.

Q: What could use some improvement?
A: Honestly, I often hear physicians voice that they do not see the need for this program and will not utilize it, or at least not to its full potential. It can be such a benefit to the patient, as well as an extension of the physician's hands so they can reach these patients at home between clinic visits. When we are utilized to our full potential, it benefits both patients and physicians. For example, if an M.D. changes diabetic or blood pressure medications, you can ask the clinical case manager to call them in two weeks and get home readings. In doing so, a clinical case manager may also be able to provide a little additional education or reiterate what was already given to the patient to help improve results. Getting those numbers to the M.D. may provide an opportunity for another dose adjustment before the patient's followup visit. The clinical case manager can follow up again with that patient to clarify new medication instructions and verify that the desired results are achieved.   

Q: What have you learned that opened your eyes to the need for this service?   
A: So often things can fall through the cracks, and there is such a need for someone to be looking for these lost items.

There are limitations to using case managers as physician extenders. However, the more we take advantage of the services they offer as part of a physician-led team, the better we are able to coordinate care, close loopholes, improve patient education and fill gaps in physician-patient communication.  

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Posted at 02:49PM Jun 29, 2016 by Kurt Bravata, M.D.

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