Every patient – you, your mother, your grandmother, your adult children – especially those with serious diagnoses and chronic illnesses – longs to be cared for by the healthcare system in a way that demonstrates they are truly known.
At the same time, too many healthcare organizations and providers don’t know enough about the patients they care for and the populations they manage.
Let me tell you about healthcare from the perspective of a patient in a high-performing system. I’d like you to meet Joseph.
Joseph and his wife, Sofia, live in Bedford, New Hampshire, nearly 45 minutes from their youngest child, Lucy. Joseph is in his early 70s, is retired and lives on a fixed income, and has two chronic conditions: diabetes and congestive heart failure.
In many ways, Joseph is a typical American patient.
- Chronic Disease Prevalence: 60 percent of adults have one chronic disease, and 40 percent have two or more.
- Diabetes: 30+ million adults have diabetes as do more than 25 percent of seniors.
- Social Determinants of Health: Nearly 70 percent of adults have unmet social needs, such as financial insecurity or loneliness. Like Joseph, almost a third of Americans experience stress over transportation needs. He also is challenged by a language barrier and a low, fixed income, which could adversely impact his access to healthcare and medication.
In very important ways, Joseph’s experience is far from typical.
His hospital, its physicians and staff know him and engage with him in a way that makes him – and his wife and only daughter, Lucy – feel cared for and connected to his hospital and its physicians.
Joseph’s hospital system has deployed a digital front door strategy – with an analytics and patient relationship management platform as the foundation – to engage patients like Joseph at every touchpoint along the patient journey.
For Joseph, this means that when he interacts with his primary care physician’s office or complex care management, they know him, his health history and priority healthcare needs such as open care gaps and social determinants of health (SDoH). For his healthcare team, it means they have the information and systems necessary to provide the right level of care and support.
Joseph regularly saw his primary care physician, Geoff Morris, DO, and was quite comfortable with Dr. Morris’ staff. He chose Dr. Morris as his primary care physician after his wife, Sofia, saw an advertisement about the importance of colonoscopies and scheduled visits for the two of them.
Joseph’s positive early experiences with Dr. Morris naturally led him to respond when a call from Deb, a nurse care manager from the hospital system, encouraged him to get back on track and schedule regular appointments to manage his diabetes and heart failure.
Joseph’s relationship with Deb began sometime prior, after a diagnosis of heart failure and admission to the hospital. When Joseph was discharged from the hospital, Deb worked with him to schedule a follow-up visit with his primary care physician and to make sure he had all of his new medications. At that time, Deb also recommended that he be enrolled in the hospital’s complex care management program, where she would stay in regular contact with him, helping him with education, support and care coordination to manage his health.
When Joseph was first diagnosed with congestive heart failure, his daughter Lucy wanted him to seek treatment at an academic medical center over 60 miles from Joseph’s home, well-known for its cardiac center.
Joseph wanted to keep Lucy happy, so he initially sought treatment at the academic medical center. Dr. Morris and Deb kept track of Joseph, continuing to help him manage his health and his care. Deb stayed in touch with him, and went out of her way to make sure Joseph’s clinical notes were brought back to the community and shared with Dr. Morris and his local specialty care physicians. She was able to set him up to receive text reminders about all of his upcoming appointments. She also took the time to educate Joseph on in-community cardiac care services and the fact that his hospital system was named one of the “100 hospitals and health systems with great heart programs.”
At one of his check-ups, Joseph spoke to Dr. Morris about getting care in the community and he was quickly connected to a cardiologist within his hospital system for ongoing, high-quality, community-based care.
At the heart of the hospital’s success in knowing and caring for Joseph in a way that makes he and his family feel engaged, understood, and cared for is an analytics and reporting platform that simplifies care coordination and patient engagement. To learn more, click here.