Coordinating Care for the Chronically Ill Through Care Networks

As healthcare providers begin to take on more risk, keeping patients, especially those with chronic diseases, out of the hospital will be a critical component for success. Pierce Story, founder and director of concept development at Capacity Strategies, believes developing what he calls a "care circle network" is one strategy providers can use to help ensure patients are cared for while outside the hospital. His latest book, "Developing a Poly-Chronic Care Network" (Productivity Press, 2012), discusses how healthcare providers can work with their communities to create care circle networks for patients with multiple chronic diseases and thereby better coordinate care and improve the health of these patients. Here, he discusses his book and the care circle network concept with Becker's Hospital Review.

Question: What was the impetus behind your writing this book?

Pierce Story: I have been working with departmental and hospital-wide capacity issues since the early 2000s. Early on, I began to realize that, just as the [emergency department] is part of a hospital, a hospital is part of a larger care system within a community. You can't optimize the capacity of the ED without optimizing the capacity of the entire hospital, because, for example, bottlenecks in other departments will impact performance and throughput in the ED. Similarly, you can't truly optimize hospital capacity without fully optimizing the local community’s 'capacity to care.'

Q: Your latest book advances the idea of a care circle network as a structure for coordinating care for patients outside the hospital. The book advances the care circle network as the more general concept and then introduces the poly-chronic care network as a more specialized network for patients with multiple chronic diseases. What are the basic components to these care networks?

The care circle network is an engineered communal response to disease management. There's been a lot of effort over the years to use community resources in the care of patients, but these programs were often haphazard and not integrated or well-coordinated. The idea behind the care circle network (and this iteration for 'poly-chronic' patients) is to better align communal resources, organize their task allocations and more efficiently link them together in order to dramatically increase our healthcare system's capacity. This will help accommodate our aging and increasingly unhealthy population, while simultaneously reducing overall cost of care delivery and improving other key metrics, such as quality.  

Unfortunately, this is not called for in the current popular business models, like accountable care organizations and patient-centered medical homes. Even these models rely on clinical resources for any care capacity expansion, and thus will run up against future resource and capacity constraints. Other great care coordination innovations, like the Naylor and Coleman models, utilize nurse navigators and care managers, and thus also rely heavily on increasingly scarce and expensive clinical resources. Furthermore, these latter models are primarily focused on short-term interventions to prevent 30-day readmissions rather than on long-term health, wellness and disease management and cost control. The care circle network is an answer to these shortcomings.

Ironically, most communities have a plethora of available and willing 'communal resources' that could augment care capacity at minimal costs if only they could be effectively and efficiently integrated into the care process. These include church congregations, civic groups, clinical residents and students, volunteers, Meals on Wheels, YMCAs, etc. The care circle network is an engineered integration of these readily available but rarely utilized communal resources directly into patient care processes. Using simple, collaborative technologies; task guidance from the patient's physician; a simple, streamlined management infrastructure; and the energy and power of community volunteers and professionals, care circles are formed around individual patients with specific needs to improve outcomes, reduce clinical deterioration and prevent unnecessary clinical interventions such as ED visits and hospitalizations.

Thus, nurse navigators and care managers might be important components of care circles, but their capacity is also augmented through the allocation of care and assistance tasks to communal resources that can more readily, easily and inexpensively, complete them.

Q: What specific collaborative technologies are used?

Essentially this refers to a 'social-clinical network' which can be thought of a patient's very own private, HIPAA-compliant Facebook. My team at Capacity Strategies worked with a vendor to create the web-based platform where members of the care circle , the patient and the patient's physician can collaborate on the various care tasks, privately exchange information and create accountability for one another.

Q: While your book explains the general care circle network, it devotes most of its focus to poly-chronic care networks. Why focus on these patients, and how might these patients be assigned to a care circle network program?

These 'poly-chronics' (defined as patients with one or more chronic diseases) are the most costly and often problematic patients in our communities; it makes sense to focus here if the additional capacity of the assigned communal resources will have a significant impact on metrics of this small but important population. If we can impact costs in this population, we can go a long way towards changing the financial constraints of the entire healthcare system.

To start in a program, a patient's physician will recommend participation, in most instances. However, if a community accepts the concept well, patients and their families may wish to have such a system created for them. I know I'd love to see a care circle network for my parents someday, and I won't be waiting for my hometown hospital to create one!

Q: What are the benefits a care circle network provides to ACOs or other provider organizations?

Frankly, since the care circle network is 'care coordination on steroids,' it is a no-brainer for an ACO. It is also a no-brainer for most of the new care delivery systems currently in play, such as PCMHs, state-sponsored delivery integration and rural health cooperatives. Indeed, the inevitable push towards capitation and reduced reimbursements for physicians, hospitals and other providers will naturally lead to the need for this sort of a dramatic care system redesign as the 'utilization turnip' is squeezed dry, and still greater capacity and lower costs are required. I would be shocked if the major ACO payors, like Universal American and CIGNA, don't jump on this concept.

There are many benefits to ACOs, PCMHs and other care delivery systems, but the more important ones include capacity expansion, cost reduction, increased patient engagement and quality of life improvement. By broadening the available resources for some care and assistance tasks, a physician's office can do more with the same paid staff, lowering per-patient cost. Since these communal resources can aid with the simple but often very important tasks that can keep patients from clinical deterioration (e.g., medication compliance, filling prescriptions, keeping appointments and support for smoking cessation and diet restrictions), there can be tremendous cost and quality benefits to any care delivery system. Indeed, early adopters of the use of volunteers have shown millions of dollars in annual savings via reductions in hospital LOS and compressing unnecessary clinical utilization. Yet, this can be accomplished with minimal resource costs.

Furthermore, if an ACO is to be what is meant to be (and not just used as a means to consolidate market share, lock out competition and solidify revenues and negotiating power), it should evolve into a truly 'communal' health system. If structured properly, then, an ACO could and should readily take in the community volunteers and civic and religious organizations that can augment capacity, control costs and better manage population health and general health education at a very local level.

Q: What are the general, broad steps hospitals need to take to explore a poly-chronic care network and then build one if they see fit?

PS: Start by examining specific patients in the population that might benefit. Depending on your scenario, you might target specific patients, specific physicians or even certain geographies from which you see unusually high admissions, readmissions or ED utilization. Choose your physicians wisely, and make sure they understand the great benefits that could come to them through participation. Patients will often self-select once shown the benefits.

If you decide to move forward, start small and expand as appropriate. I normally offer to start a client with as few as 20 to as many as 60 patients during an initiation six month ramp-up. Build on your existing community relationships that lie throughout your hospital, from the C-suite to case management. Use existing resources, such as case managers and nurse educators if you can, then expand into full-time roles as needed. Of course, acquire the right collaboration technology for your circles. You don't need to spend a fortune creating your own or having your EMR vendor customize something for you, as it is already developed and ready for use. The book lays out a pretty detailed 'to do' list, including step-by-step guides and a list of the possible pitfalls. It's not hard, but there can be 'witches behind the trees' that you need to be aware of.

Q: What are some of the major financial implications for developing a poly-chronic care network?

PS: Although it offers benefits in areas like reducing readmissions and unnecessary clinical utilization, expanding physician relationships, improving community outreach, etc., this is not meant to be a big revenue-generator for hospitals, which is why some immediately reject it. Though there are innovators who see that the inevitable future is now and are prepping for it by implementing cost-reduction and cost-avoidance programs like the CCN/PCCN, many hospital leaders are, rightly or wrongly, tightly focused on volume, revenues and market share. While the care circle network concept can indirectly help these metrics, this program is about reducing cost, not increasing revenues. It is about improving capacity and quality, not growing EBITDA.

Fortunately, the costs of the program can be quite minor when compared to the total cost of an ED visit or other unnecessary clinical intervention. Since currently employed resources or even volunteers can be used in the management of the program, costs can be as minimal as the software required. This becomes a drop in the bucket as we look to CMS penalties for failures to perform.

I believe that as providers are pushed increasingly towards the new business models like ACOs, bundled payments and capitation and suffer penalties for failing to effectively control system operations, this concept will be increasingly accepted as a viable means to control total cost of care delivery while maintaining/improving quality, and improving patient access.

Q: What seems unique about this model to me is that it really seems to engage the patient in their own care, more so than other navigator models.

Exactly. I think there are some ancillary benefits that people often don't think about. There's a 'culture of irresponsibility' that's grown out of our healthcare system. We see patients in hospital gowns outside the hospital smoking, and obese people in line at fast food restaurants all the time. We have to change the culture of disease and responsibility and one way to start to do that is through better educating people about disease and what they can do to prevent it through communal groups and resources.

This is a perfect time for this sort of model. As we look to a resource and financially constrained health system, there is little doubt that radically new business and care models are required. We simple may not have the clinical capacity required for this next generation of patients. And even if we did, we likely won't be able to afford it.

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