Let me tell you about a patient, whom I’ll refer to as Esther Simmons, and who recently participated in our oncology case management program, as she neared the end of life. Our analytics identified her as a one who could benefit from personalized case management and would be likely to participate, and she agreed.
Trifecta. Now let me tell you why.
Throughout her illness, our nurse case manager worked closely and on a personal level with Esther and her family to address both practical and emotional challenges of this journey.
One of the many outcomes of the case manager’s work with this patient and her family is that, at the end of life, Esther’s comprehensive care was well coordinated and her wishes met. While healthcare dollars were likely saved because of that, the true measure of the impact our case manager had was perhaps best reflected in a letter received from our patient’s husband after her passing. He sent a letter saying that Esther’s personalized case management was appreciated and our nurse was a wonderful person who was “informative, always helpful but never pushy.” He added that after conversations with the case manager, “She [my wife] was happy, and seemingly her pain was forgotten for a moment in time.”
As the manager of Geneia’s case management department, I am charged with helping patients like Esther who are experiencing complex and catastrophic health issues. I’m held to both clinical and financial performance standards, including demonstrating a positive return on investment. Still, when I want to understand the impact my department is having on our patients’ progress, I go first to the comments provided on our patient satisfaction surveys like the ones written by Esther’s husband. And that’s because I’ve found that when we as clinicians do our job well, when we take the time to learn about the personal, cultural, and psychosocial factors that impact our patient’s ability to manage their health, the numbers will indeed move in the right direction.
Population Health versus the Individual
By numbers, I mean population health trends such as admissions per 1,000, improvement in HEDIS scores against an agreed-upon benchmark or demonstration of an aggregate decrease in the HbA1c levels. In order to meet this demand for numbers and data, analytical tools are pulling in wider bands of information in order to illustrate patterns of utilization, identifying opportunities to increase efficiencies, and prioritizing patients who need additional attention, but with emphasis on the individual.
Reporting packages are becoming increasingly detailed, and varied slices of the data are immediately available to our clinicians. Indeed, the amount of unique data being produced is quite impressive and offers exciting possibilities for individuals and their likened populations.
While I know that numbers and data matter, I’ve learned that numbers won’t move in the right direction if we lose sight of the individual needs of the patients behind those numbers. Improved analytics and algorithms are streamlining many aspects of healthcare, but they cannot account for the inherent strengths and vulnerabilities that make each person unique, the variability in patients’ understanding of medicines and tests or their level of comfort with medical terms or their reactions to clinical diagnoses. Culture, faith, personality, informal supports, and other psychosocial factors all need to be accounted for as discussions are held with patients to help them plan for the care and tests they need or to effectively deal with test results. An empathic ear and a patient-centered perspective will go a long way in helping patients like Esther cope with diagnosis and treatment.
It’s my work to effectively marry analytics and predictive modeling with personalized case management care to help Esther and many others like her.