Redefining Ambulatory Care Management for Results

Many organizations have invested heavily in population health tools and technology used to identify patient risk and support workflow. A great deal of work has gone into improving the accuracy of these risk models and assuring that the correct patients are identified. These systems are largely doing a good job as it pertains to letting patients know it is time for a mammogram or other preventative test and identifying the highest risk patients.

It is when we get to the point of “touching the patient” to prevent disease escalation that things often start to unravel.

The best tools and analytics cannot compensate for a poor design at the patient touch point. Many organizations would be well served to redefine the meaning and purpose of a care plan. Many organizations simply do not have a good understanding of what a care plan needs to look like to prevent disease escalation.

Here are some key elements to consider when redefining a care plan and care plan execution:

  • Set goals with patients using personal objectives to motivate and activate – Comprehensive Shared Care Plan (CSCP)
  • Build confidence in the patient to promote self-management
  • Consolidate all existing “care plans” and do detailed medication reconciliation into one to avoid duplications and conflicting information
  • Identify and remove the barriers to care plan execution
  • Ask the right questions to catch critical clues and address them
  • Provide practical, clinical, social and behavioral support for patients

 

Change the Definition of Care Management and the Care Plan

Many “care plans” contain missing, conflicting, and duplicative information, and in general, are poorly designed. A well-designed plan that can and will be executed is much more than a care plan. It is a comprehensive shared care plan (CSCP) that embeds itself in the culture of the organization.

A care plan is clinical documentation of clinical tasks, whereas a comprehensive shared care plan (CSCP) is a practical and engaging guide to self-care.

The problem that often exists in human nature is that there is something that is called a “care plan” so people fail to see that it often completely misses the point. This terminology is so ingrained that it can be difficult to see past it and realize it is not really a care plan at all. We will compare the details of the traditional care plan to the comprehensive shared care plan in the remaining article.

What is also interesting to note is that we have had traditional care managers audit these actual scenarios and they did not see shortcomings in the recent assessment examples shown below. The examples contained here are from real life audits of organizations who have not built the infrastructure nor culture to impact results and those who have. You will notice the interconnectedness of these points and situations.

 

Collaborate to Set Goals that Matter to Patients and Families

Traditionally, a clinician sets the agenda for a conversation with a patient; they have limited time and needed to address key concerns and communicate their “orders” efficiently. The belief that behavior change came from a place of knowledge drives the norms of informing patients of their “things to do list” in clinical terms. The goal is to get them to be compliant and let the caregiver make the decisions.

To engage patients and promote self-care, there must be a shared agenda with goals that matter to the patient (they must be motivated). Collaborative goal setting is a key element of a comprehensive shared care plan (CSCP) that embeds itself in the culture of the organization. This approach becomes a more engaging guide to self-care.

Collaborative goal setting is of the utmost importance to motivate and activate patients and families.

Examples from a recent assessment and audit of “care plans.” A patient who had multiple readmissions and visited the ED frequently showed care plan goals of “taking all 20 medications as ordered and weighing themselves for weight gain.” The patient’s personal goals were not established.

Contrast that to a patient who shared with their health partner that “dancing at my grandson’s wedding” is a personal goal. Now a shared goal exists, helping the patient understand that the medication will be useful in achieving their goal helps motivate. An engaging plan will begin by understanding what the patient chooses for themselves which provides motivation.

 

Build Confidence to Promote Self-Management

Traditionally, it has been held that behavior change comes from knowledge. If we educate our patient, they will comply. Collaborative self-management involves building confidence as well.

Examples from a recent assessment and audit of “care plans.” A patient who had multiple readmissions and visited the ED frequently showed care plan goals of “taking all 20 medications as ordered and weighing themselves for weight gain.” The Care Manager noted that the patient expressed a lack of confidence in doing either of those activities (a confidence 4-5 on a scale of 1-10 was documented). No support was provided for helping the patient.

Compare that to an obese lady with high blood pressure and diabetes. The patient admitted she wasn’t taking her Glipizide. She also admitted that she was not taking her Metformin due to a side effect of it making her feel shaky. Her Health Partner began encouraging the patient to take her medication but also to begin some small amounts of exercise. The patient began by walking. Next, she requested help getting diabetic shoes for walking as well as help lower the cost of her prescription copays which were about $100/month. With continued encouragement, the patient lost 35 pounds and no longer needed the diabetes medication.

 

Consolidate All Existing “Care Plans” (including medication reconciliation) Into One to Avoid Duplications and Conflicting Information

It may seem obvious but complex patients often have multiple uncoordinated care plans. This leads to medication mix-ups, lower engagement, and higher costs. It also leads to lower confidence in complying with the actions as previously discussed.

A patient with only one working kidney was prescribed a heavy anti-depressant which caused his kidney function to drop and he became critical. The PCP didn’t know why (she had no idea patient was seeing a psychiatrist or was on an anti-depressant) because the care was uncoordinated. In this case, there was no care manager.

Compare that to another example where a patient with COPD visited multiple specialists. Each specialist had prescribed a different inhaler. The patient was using 5-inhalers. This created not only a risk of overmedication for the patient but also a huge financial burden. His health guide realized that these needed be consolidated. The result was a single inhaler which was generic (minimal financial impact).

 

Identify and Remove the Barriers to Care Plan Execution

It cannot be overemphasized that the tiniest details matter in assuring a patient can execute their care plan. Many chronically ill patients are seniors and what was once a not a problem is now a significant barrier to engagement and compliance. It takes time to manage the details, but it is essential to supporting the success of patients and lowering overall costs.

A recent example from an assessment was a diabetic man who was homeless but “couch-surfing” with friends and family. His care manager gave him a “care plan action” to “ask his friend for $10 to purchase test strips”. A side note, he later ended up having his leg amputated.

Compare that to a diabetic gentleman who was blind and a double-amputee. He was unable to get his medication refilled because his date of birth did not match what Medicare had on file. Historically, providers had changed his date of birth to match Medicare’s, but this pharmacy refused to do that as the man assured them that it was his actual birthdate. The health partner helped him obtain a copy of his birth certificate, collected a physician’s attestation and went to the social security office to get the record corrected.

 

Provide Practical, Clinical, Social and Behavioral Support for Patients

Many actions are simply impractical given a patient’s situation. Simple practicality is of the utmost importance in working with patients to build confidence in executing their plan.

A recent example from an audit was an elderly woman with multiple chronic conditions who had a home visit from her care manager a day after she was discharged from an inpatient stay. The care manager noted a large hemorrhage area on the right eye and shooting pain. The care manager did not have a blood pressure cuff with her and instructed the woman to go to urgent care to get her blood pressure checked. The woman did not drive and relied on others to take her places.

Compare that to another example was a patient that trusted their health advocate enough to ask for help. “I live with my sister and we are both alcoholics. I really want to stop drinking but I don’t drive, and she will prevent me from getting help.” The Health Advocate found an inpatient treatment center to pick up the patient. Two months later, she was discharged sober to her own living arrangement, was attending AA daily, and had maintained her sobriety for more than 8-months.

 

Build a Trusted Relationship by Providing a Single Person as a Point of Contact

Touchpoints by a consistent person with patients must demonstrate active listening skills and action to build trust and engagement.  Listening and building trust is part of a plan to care which embeds itself in the culture of the organization. When you do something helpful for someone, they are more likely to share more with you and become more engaged (principle of reciprocity).

A recent example from an assessment and audit was a patient who told his care manager that he was “depressed and drank a bottle of vodka and took twice the normally prescribed pain medications the day before.” The care manager notated this and told the patient “you should drink less.”

Compare that to an obese lady with high blood pressure and diabetes. The patient admitted she wasn’t taking her Glipizide. She also admitted that she was not taking her Metformin due to a side effect of it making her feel shaky. Her Health Partner began encouraging the patient to take her medication but also to begin some small amounts of exercise. The patient began by walking. Next, she requested help getting diabetic shoes for walking as well as help lower the cost of her prescription copays which were about $100/month. With continued encouragement from her health partner, the patient lost 35 pounds and no longer needed the diabetes medication.

 

Ask the Right questions to Catch Critical Clues and Address Them

Whether it is due to time constraints or other factors, the assumption is that the patient will tell you what you need to know to help them.

To do great care management you must dig deeper to be able to get to the real issues.

A recent example from an assessment was a patient who had COPD and had developed pneumonia. Her physician wanted to admit her to the hospital, but she refused because she had no one to take care of her dog. The care manager visited her at home the following day and found that she had no meds and the patient said she “felt feverish.” The care manager did not take her temperature but told her “go get your medications.” The problem was that the patient did not drive and ended up in the ED 2-days later.

Compare that to a gentleman who shared with his health partner, “I can’t sleep well at night.” Instead of asking his physician to prescribe sleeping aids, the advocate dug deeper and asked the question “what is going on that you cannot sleep at night?” The patient responded: “my mattress is very bad, and I cannot afford a new one.” The health advocate listened and acted, which involved contacting a local charity that happily delivered a mattress to the patient.

Wherever you are in your journey of population health and ambulatory care management, there is always room to learn and improve. You will learn the most by auditing records from your own organization instead of asking people what they do. Observation is at the heart of learning. Building a well-run care management organization takes design, infrastructure, and attention to detail.

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