Defining the Role of Meaningful Chronic Care Management Programs

April 23, 2018

With the shift from fee-for-service to value-based care, fragmented approaches to delivering quality Chronic Care Management are no longer sustainable.

The key to managing the health of a growing population of chronically ill patients requires a mix of leveraging technology, and hiring the right people to mine data for insights and trends. Has a diabetic patient’s blood glucose levels spiked in between visits? Maybe a tragedy in the family caused stress. Does a patient understand why they need to have dialysis? Perhaps they are missing appointments because a provider, overburdened by a packed schedule wrote the referral without answering unresolved questions about the procedure.

“As CareThrough engages to drive a meaningful impact to the growing population of patients with chronic conditions, it’s our aim to make a material difference, for the patient, and for their families,” says CareThrough President, Kyle Cooksey. “Just this week, I learned about a specific instance where our Care Team’s engagement with a patient lead to a discovery around arising challenges with breathing, but the patient was scared and wasn’t sure what to do. Fortunately, because our Care Coordinator was activated within their structured plan, they helped the patient uncover the root cause to avoid unnecessary and costly outcomes, which, in this case, was a lack of adherence to their medication plan.”

Health coaching, medication adherence support, referral and specialist scheduling are some of the critical areas where targeted care coordination extends providers’ ability to impact patient outcomes, beyond the clinical setting. With continuity of care, value-based goals become achievable.

“We see the reality that there is a true need to reduce unnecessary patient encounters through care coordination and because of that, we were able to see a real difference made in this specific life,” says Cooksey. “To me, the most meaningful outcome was a follow-up call that came a few days after the escalation through normal plan-adherence, where the patient thanked the coordinator and acknowledged how important they were to her life, and how she felt much safer knowing she was cared-for and mattered to us and her PCP.” 

These are the types of qualitative, social determinant of health questions that patient navigators within a robust Chronic Care Management Program will investigate with periodic follow-up, and the answers have quantifiable results.

“Operationalizing the shift from volume to value depends on rethinking healthcare delivery,” says HealthChannels Chief Strategy Officer, Craig Newman. “It means engaging patients outside of the clinical setting, meeting them where they are, and listening well.”

Developing care management strategies, Newman found that committing to a CCM model that takes a holistic look at patient’s health and significant factors inhibiting access to care creates better results, rather than relying solely on labs and EHRs. Not only does this approach lead to better health outcomes, but also reduces missed opportunities to bill for Medicare CCM codes and RAF scores, amounting to millions of dollars in revenue over time.

“It’s important to make incremental shifts,” says Newman. “Helping patients navigate their healthcare is one way providers can begin to achieve larger quality care goals.”

Yet many healthcare systems simply do not have the bandwidth to train internal teams or scale current programs to identify at-risk patients, provide remote care, and close care gaps. CCM may take persistence to enroll the maximum number of patients you can reach, and to engage them in meaningful conversations is no easy task. It’s no wonder providers have expressed frustration, knowing they were missing ROI targets with their outdated approach.

We saw this recently when Tristan Health Systems in Massachusetts enlisted CareThrough to design a CCM program that moved the needle. Previous attempts to manage patients with multiple chronic conditions didn’t produce results and strained nursing staff. First we gathered baseline data before we imbedded a patient navigator program model that built awareness and engaged patients. Within months, Tristan Medical Systems saw five times increased revenue.

“I’ve been a healthcare investor and operator for over twenty years in private equity,” says Jeff Ward, Tristan CEO. “I have seen ancillary programs cause administrative burden. CareThrough understood our concerns and has been a low risk partnership, providing us with a trained navigator at the greatest value.”

Our approach begins with hiring and training qualified navigators to help patients define personalized care goals, and population health management strategies. We developed our full turn-key methodology with insights from fellow HealthChannels company, ScribeAmerica, the leading provider of medical scribes. ScribeAmerica’s turn-key model combines decades of HR expertise, EHR systems know-how, and the insights that can only come from years of training scribes to work elbow-to-elbow with providers. CareThrough navigators are encouraged to communicate with doctors, quickly identify at-risk patients, and use EHRs to close care gaps while optimizing codes for accurate billing.

“We look at the healthcare provider’s entire system, and define care-coordination opportunities to adress social determinants of health before deploying a navigator to connect with patients,” says CareThrough Director of Operations, Matthew Glowinsky, MSW. Knowing that provider collaboration is an important factor in quality care navigation services, Glowinsky develops customized programs that allow clinical staff to operate top-of-license, while navigators connect patients to community resources.

Ideally, once your CCM program is set up, and the navigator is on the ground, the integration happens seamlessly. But generating engagement is dependent on one of the more daunting challenges— building patient trust.

“Many of the patients we speak with are weary of receiving unsolicited calls,” says Tristan CCM Navigator, Shannon O’Connor, “It’s one of the challenges we face as care coordinators. There’s often a barrier to initial conversations. Once I let them know that my focus is on their well-being, and that I’m available to help manage their medications, or find transportation for their doctor’s appointments, the mood changes significantly.”

The results from Tristan Medical System underscore what we believe is a CCM model that works, that patients have responded to, and healthcare system CEO’s have lauded. Thanks to the help of our navigator who provides easy-to-understand information to patients also due to her sociology background, we have optimized the program to produce results. We also utilize proprietary software to ensure that doctors have the most up to date information so that follow-up appointments are more successful.

According to Virginia Burchett, Principal of Virginia Burchett Consultants who has created and reviewed multiple CCM programs, CareThrough excels by choosing the right people to deploy, who can work seamlessly with providers and clinical support staff. For her, the Human Resources component is more than half of the battle.

“Chronic Care Management is not a one-size fits all solution” says Burchett, “And having a CCM program is not synonymous with patient success. Having the right design, with the right people, and knowing the predictors of a good program, saves lives.”