Care Coordination: Cacophony or Melodious Symphony

May 23, 2018
Shelley Riser RN, BSN, MSHA, Vice President, Consulting Services and Clinical Innovation


Image of 40 something Hispanic female sitting

Take a listen to these two recordings. Just listen to the first 30-60 seconds. You’ll quickly get the idea.

No matter how adorable you find the 10-year-olds in the school band, it’s the Chicago Symphony that’s melodious and beautiful.

It’s an apt comparison for care coordination from the patient’s perspective. Is it a cacophony or a symphony?

Despite the best of intentions, I suspect that far too often it feels cacophonous to patients. 

Care Coordination & Prediabetes Patient Lucy

Earlier this year, we introduced you to Lucy*

Image of Lucy the Patient smiling

To refresh your memory, Lucy is 42, a mother of two teenagers and a part-time caregiver for her elderly father. Given the demands of her job and personal life, it’s quite possible she’s the kind of person who would be tempted to put off regular check-ups and preventive cancer screenings. That’s why it’s a good thing that Lucy’s employer, Lightning Laser, has a benefit plan that incents employees to choose a primary care physician.

Lucy is one of the lucky ones. 

After all, approximately 84 million American adults are prediabetic, and 90 percent don’t know they have it. That’s one in three adults with prediabetes, and the overwhelming majority - 70 percent - will develop diabetes, a costly chronic condition with potentially devastating impacts and even early death.

The single best way to prevent prediabetics from progressing to diabetes is to engage them in a healthier lifestyle comprised of physical activity and weight loss. If you think about the number of us who create New Year’s Resolutions to exercise more and eat less and abandon them well in advance of Valentine’s Day, you already know how challenging lifestyle changes are for most of us. Anecdotal evidence and statistic results show losing weight is far from easy for most Americans. Each year, 45 million Americans go on a diet, and experts say as few as five percent keep weight off long term.

Some say it takes a village to work with prediabetics like Lucy and motivate them to become active participants in their good health. Given how challenging it is to engage and sustain motivation to eat well and move more, I say it needs to be a symphony of coordination and alignment between Lucy, her physician and care team, her health plan and her employer. Just as importantly, they need a shared tool to communicate and collaborate.

The Cacophony

Not long ago, health plans focused their care management resources almost exclusively on chronically-ill and catastrophically-ill members, assigning a case or disease manager to people with illnesses such as heart failure, COPD and cancer. These care managers would send a letter and perhaps follow up with regular calls if they were fortunate enough to have the member’s phone number.

Chances are the physician’s office would write and call too. And in some cases, the hospital and health system also would contact the member.

Imagine you’re Lucy.

You’re already a bit overwhelmed with the demands of your personal and professional life. Then your physician lets you know you have prediabetes, and the only cure is to get actively engaged in your health. You may not know how to begin. Perhaps you’re like many Americans and have already tried many times to no avail to lose weight and improve your health. And then the letters and calls start.

The Symphony

At Geneia, we have a different vision, one that allows all of the people and organizations that want to help Lucy to work together with her, to give her the kind of personalized, patient-focused care that gives her the very best chance of being one of the 30 percent of prediabetics who do not progress to diabetes.

For the first time, Lucy’s physician and care team, her health plan and her employer are all able to use Geneia’s Theon® analytics, insights and care management platform. They use the platform to improve their individual effectiveness but also to have real-time insight into how others are working with Lucy.

For example, Lucy’s physician and care team use the Theon® solution to monitor her progress on her care plan, including annual measurement of her BMI and nutritional counseling. Lucy’s referral to her health plan’s health education program was done within the platform, and her health plan care manager views Lucy’s record in the Theon® platform to see that her colleague in health education has already reached out and enrolled Lucy in the right program.

From Lucy’s perspective, she has a coordinated team, one that feels much more like an orchestra comprised of players that each have different, important and complementary roles in helping her improve her health. 

 

*Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.

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