4 Principles to Guide Effective Chronic Care Management

Chronic care management, which includes the monitoring and addressing of chronic diseases such as arthritis, diabetes, obesity and heart disease, is a challenge for any hospital or medical group. Inducing patients to be active in their own preventive healthcare by itself is not enough, and hospitals and medical groups need to consider different principles to keep patients healthy, which will lead to less bed overflow and more cost savings. Joe Berardo, CEO of MagnaCare and author of the white paper, "The New Face of Chronic Care Management," shares some insight on how proper care plan management can impact chronic care.

1. Incent providers to work with chronic patients. Mr. Berardo says one of the most important principles is giving providers an incentive, financial or otherwise, to pull patients into the healthcare system instead of merely putting the onus on patients. "In order to impact trends, there needs to be an increase in the urgent-care setting and around incenting providers to work with patients to minimize avoidable admissions," Mr. Berardo says. However, care plan management needs to reimburse for this type of consultation or for improving patient health status, Mr. Berardo notes, so the physician will feel time spent with patients going over all preventive options is valued.

2. Integrate electronic health records and care plan management. Implementing EHRs makes sense, especially on the provider side, Mr. Berardo says. But every provider does not have all information on a given member since it is rare a patient stays with one hospital or physician for his or her entire life. Health information exchanges, for example, are being implemented to share this type of information among certain geographic populations and health systems. Hospitals and providers who fall outside of a HIE can also consider working with care plan management companies, which would be able to obtain the patient's history from all past providers, perhaps saving them time, says Mr. Berardo. So while EHRs, as well as HIEs, are the wave of the future, there can also be the flexibility between small, rural providers; larger providers; and care plan management companies to share that health information, he says.

3. Utilize data analysis to improve member health status. Mr. Berardo says we all need various preventive screenings throughout our life to avoid chronic conditions before they start, but generally speaking, many people just don't take advantage, even if it's covered. However, once EHRs are actually in place, data from those EHRs can be analyzed and transformed into valuable information. It can be used to educate people and providers to get certain preventive screenings or take steps to manage their current condition. For example, he says providers may not have seen a diabetes patient's hemoglobin measurements for a while, prompting the provider to reach out to that patient.

4. Realize that the accountable care organization discussion is helpful but not a panacea for chronic care. Approximately $40 million in Patient Protection and Affordable Care Act funds will be used to bolster statewide chronic disease prevention programs, and the PPACA also encourages hospitals and medical groups to form ACOs, as well as wellness and prevention programs, in order to cut costs. However, ACOs encouraged by the PPACA are not the right focal points for handling chronic care management for the entire population because there are too many restrictive measures. Instead, the more basic hospital or provider system of financial incentives found in ACOs is the most helpful structure, Mr. Berardo says, because it could lead to good outcomes for patient health as well as efficient management.

Related Articles on Chronic Care Management:
HHS Issues Framework for Managing Patients With Multiple Conditions
Access to Primary Care Doesn't Assure Better Outcomes
More Than One-Third of California Inpatients Readmitted Within a Year

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