Engaging the Chronic Care Patient

Joe Cantlupe, for HealthLeaders Media , November 13, 2013
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The NHRMC has a network of nearly 500 physicians from various hospitals to coordinate care, and serves a population of 1.2 million. Between 2007 and 2010, Community Care of North Carolina saved Medicaid nearly $1 billion, according to an evaluation by Milliman Inc., the CCNC stated. The coordination of care has resulted in a 20% reduction in readmission, compared to clinically similar patients who receive care, says Paul J. Mahoney, vice president of communications for CCNC.

When case managers review patient files and visit them, sometimes they find the root of their physical problems don't have anything to do with clinical issues but environmental issues that the hospital may not have spotted initially, Whisnant says. "A patient may feel they can't control their child's asthma. Then you find out the patient has a dog sleeping on the bed with that child. Does that have something to do with it?" Whisnant asks.

"Maybe a baby is having trouble breathing in the home, and then you find out they are scrubbing the floor with ammonia and the window isn't being raised" for ventilation.

Patient satisfaction scores in a 2013 report show that 82% of NHRMC's discharged patients said "yes," they would definitely recommend the hospital, compared to 71% of the North Carolina average and 71% of the national average. The figures were part of a survey of at least 300 patients from October 1, 2011, to September 30, 2012, according to Hospital Compare data.

In Illinois, the Chicago Medical Home Network focuses on a remote home monitoring program to more accurately identify at-risk patients and improve patient engagement and satisfaction. The network includes hospitals and dozens of clinics and physician practices that have agreed to cooperate and improve basic care for Medicaid patients, and they are linked through an Internet portal.

The participating Chicago hospitals are the 895-bed Cook County Health and Hospital system; the 160-bed Holy Cross Hospital; the 49-bed La Rapida Children's Hospital; the 319-bed Mount Sinai Medical Center; the 664-bed Rush University Medical Center; the 395-bed Saint Anthony Hospital; and federally qualified health centers.

Like some other hospital programs, the Chicago-based Medical Home Network, a collaborative of 12 hospitals and 110 team-based primary care medical homes, uses an electronic system to alert physicians when Medicaid patients are admitted, discharged, or use an emergency department, and the reasons why. MHN's secure Web-based portal, MHN Connect, also provides access to complete patient medical history to physicians throughout the world.

MHN goes one step further, says Cheryl Lulias, its president and executive director. MHN also operates a remote home monitoring initiative for hypertension and congestive heart failure patients at seven partner clinics.

Patients receive wirelessly connected technology that transcribes their medical readings in an encrypted fashion to a secure network, which, if necessary, triggers an alert to physicians. MHN provides the equipment free of charge to the patients. The equipment includes blood pressure cuffs and scales. Each device is battery operated and equipped with Bluetooth technology, which wirelessly transmit diagnosis readings to a cellular pod than then encrypts the readings and relays them to the portal.

From there, MHN facilitates data analysis, synthesizing real-time biometrics with the wealth of data available in its MHN Connect portal, resulting in actionable tools for chronic disease management.

The technology alerts help engage patients, and they are happier about the process, Lulias says. By enabling clinicians to monitor patients in real time, for instance, doctors are able to "mitigate the 'white coat' effect on blood pressure readings that occur during office visits, a temporary condition that can confound readings and lead to mismanagement of hypertension," Lulias says.

The remote monitoring program is one part of MHN's broader mission to drive better health outcomes for its target population. One of MHN's key performance indicators is for patients to receive follow-up care in their designated medical home within seven days of being in a hospital or having an ED visit. In December 2012, MHN reported 19% of patients were routed to medical homes within a week; and in six months, it was 23.4%, which Lulias sees as good progress.

"We're trying to reduce readmission, inappropriate hospitalizations, poor chronic care management, and preventable ED visits," Lulias says.

The personal communication between staff and patients has encouraged both, she says. "Through our efforts, we are working to engage patients, support healthier behaviors, and build healthier communities.

"We have made competitors collaborators for this initiative and have organized around a shared vision and purpose," says Lulias.

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This article appears in the November issue of HealthLeaders magazine.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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