By Mark S. Dwyer and Heather Jacobs
According to the US Centers for Disease Control and Prevention, chronic disease contributes to more than 75 percent of our national health expenditures. Persons with chronic health conditions account for 84 percent of all healthcare spending in the United States and are the most expensive users of healthcare services (Anderson, 2010). Furthermore, according to the Agency for Healthcare Research and Quality persons with multiple chronic conditions cost up to seven times as much as those with only one chronic condition (AHRQ, 2006).
Historically, care plans were designed to independently manage single chronic conditions such as heart failure, COPD, diabetes, adult asthma, pneumonia, and others. These early care plans effectively helped care coordinators assist patients in managing one chronic condition at a time.
But what about patients with multi-morbidities?
A better way was needed to address patients who suffered from two, three, or more chronic conditions. Until now, addressing a patient’s multiple needs meant managing the patient in multiple care plans. Doing so resulted in duplicate calls, redundant questions, and repetitious sharing of health data.
The 2013 AMA recognition of obesity as a chronic disease has further extended the need for integrated care management. Obesity is at epidemic levels throughout the United States. (See part two of Traci Haynes’ article on obesity). Often this directly relates to other chronic conditions such as diabetes, making it no longer realistic to manage these conditions independent of each other.
To address this, comprehensive health coaching programs enable RN care coordinators to manage the health of multi-morbidity patients. These plans help identify the appropriate surveys to complete with the patient, the information to send, the health statistics to gather, and the goals to set, all within a single call. This allows care coordinators to use their critical-thinking skills to identify the appropriate information to share during any call.
How it Works: Patients are enrolled into a single, dynamic care plan that can be customized to meet each patient’s unique needs and multi-morbidities. Once enrolled, contacts between the patient and care coordinator are scheduled as needed as opposed to following a rigid fixed frequency.
As part of the initial and annual follow-up calls, the care coordinator can gather baseline data, medication adherence, and other health information that does not change often. The baseline data allows the care coordinator to assess the patient’s needs regarding multi-morbidities, service needs, adherence to basic self-management, and desire to change behaviors.
There are two primary plan frequencies to consider: comprehensive and high frequency. The comprehensive plan is designed to follow-up with the patient on a less frequent basis (such as, quarterly) while the high frequency plan involves contacting the patient on a more frequent basis (perhaps weekly or monthly). Both plan frequencies address medication adherence, standards of care, and optional goals.
Based on updated standards of care, the care coordinator uses surveys to gather data on the HEDIS and disease-specific medical care standards, as recommended by the corresponding accrediting organizations and authorities. In addition to surveys defined for each disease state, the system also includes the Zung Depression survey and Diabetes Distress Screening (DDS17).
Once the appropriate data is gathered, the care coordinator can access appropriate resources as needed. This information is shared with the patient using email, text, or paper format. Many of these health information topics are authored by the AAFP (American Academy of Family Physicians) or MedlinePlus.
Two other key surveys involve goals and medications. The goals survey is optional on any encounter or may be used as a standalone contact to work with the patient in setting goals and evaluating progress. Although the medications survey is also an option as a stand-alone contact – to work with patients on medication adherence, education, and needed resources – it is recommended to update it with each encounter.
Key reporting tools are available to assist with patient assessment and streamlined call processing. Reports can give care coordinators a quick way to view the patient’s health history, lab values, appointments, and goals. In support of this, an adherence scorecard report alerts care coordinators to any behaviors that need to be addressed during the contact. If desired, the patient’s physician can be notified if the patient opted in or out of the program, any goals identified, DDS17 results, depression screenings, and the patient’s adherence to the standards of care.
Key Components: A comprehensive health coaching program should include the following components:
- Patient Engagement: A centralized tool to turn referrals into interactions and facilitate the connection and coordination of care across the patient care continuum.
- Self-Management: Built-in tools to teach patients self-management behaviors, including medication adherence, and self-monitoring (peak flows, blood glucose, weight, and so forth). Medication errors can be avoided with the program’s reconciliation and adherence tools.
- Patient Goals: Identify care gaps using health risk assessments and surveys to set relevant goals with the patient. Track progress and refer to network providers or community services based on the patient’s benefits.
- Behavior Change: Drive change with health coaching tools aimed at both the patient and family members. Ongoing contact and consistent messaging managed by the outreach scheduling tool are critical to permanent behavior change.
- Improved Outcomes: With timely intervention, paired with healthy patient and family engagement, patients are readmitted less often and are more satisfied with their care.
- Measure Results: Trend readmission rates provide clinical outcome reports to track enrollment and demonstrate success.
In light of the country’s aging population and overall poor diet, the likelihood of individuals needing multi-morbidity care management services in the future is likely to grow. Fortunately, emerging health coaching programs provide the infrastructure upon which to effectively improve care, education, and behavior modification. The result can provide healthier outcomes for patients, increase customer loyalty, and positively affect an organization’s bottom line.
Mark S. Dwyer, COO, and Heather Jacobs, manager of client services, both at LVM Systems, providers of Poly Plan, a health coaching program that provides the infrastructure to effectively improve care, provide education, and encourage behavior modification. For more information, contact Heather at heather@lvmsystems.com or 480-633-8200 x333.