Care management is a strategy primary care practices use to manage the care of populations. Developed in response to the limitations of providing care only within the four walls of the clinic, it is a way to improve the patient experience and health of populations while decreasing the cost of care — the Triple Aim. It is focused on identifying high-risk populations and using skilled staff to manage care in order to reduce hospitalizations and emergency department (ED) visits.1 Ideal care management programs are team based, patient centered, and dedicated to population management as opposed to disease management. Because it is vital to primary care, we've made care management the theme of this issue of FPM.
At the health system where I work, we hired registered nurse care coordinators to work with patients at high risk for frequent ED visits, hospitalizations, and readmissions. Our experience makes me optimistic that care management will also greatly benefit the health of the care team, the additional component of the Quadruple Aim. Having a nurse check in on our most complex patients helps the entire team provide better care and reduces my workload. Prior to the pandemic, the nurse provided health education and counseling when these patients came for appointments. Currently, she works virtually and calls patients after their visits with me, whether in person or virtual.
Our care management model has benefited both the team and the patients. In my practice, where the care coordinator follows 10 of my most complicated (and high utilizing) patients, the highlights include decreased phone calls, more direct communication with long-term care facilities and home health agencies, and improved hospital follow-up care. I feel like I am part of a real team with another skilled health professionals focused on optimizing the health of my patients and keeping them out of the hospital. One patient who was in the habit of sending at least one email a day to the practice (the most was seven emails in a 24-hour period) cut down his messages significantly after he started working with the care coordinator. When he did email, the nurse was able to triage the messages, directly decreasing my workload.
Siobhan is the nurse who works with me. Her more frequent interactions with patients provide me insight into what they are experiencing in the home setting. For example, she noticed that a patient was confused during a scheduled phone call. We were able to get the patient in to our office, where she was diagnosed with a urinary tract infection, potentially preventing an ED visit or hospital admission. Another patient in an assisted living facility had a blood glucose reading in the 400s. Siobhan contacted staff at the facility and determined he'd just eaten an entire birthday cake. She worked with the facility and his family to limit the amount of sugary snacks he had access to, which has helped with his blood glucose levels.
One study looking at patients' perceptions of care management found that most of the 43 patients interviewed felt that their care manager was a valuable member of their health care team.2 However, 20% of patients could not identify their care manager. The authors suggested practices could optimize the use of care managers through in-person introductions (which may be difficult during the pandemic) and clear identification of the team by the primary care physician.
My patients enjoy Siobhan's care coordination. They tell me they like someone checking up on them, and they appreciate talking to the same person each time they call the clinic. She has certainly saved me time and improved the care of some of my most complicated patients, which lets me worry about them a little less.