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Care Coordination: the key to sustainable healthcare

by Barry Bittman, MD

The challenges of ensuring sustainable high quality healthcare for our nation must not be underestimated. This highly complex system with current expenditures exceeding $2.6 trillion per year cannot continue in its present state.

The system is broken. 

While our nation expends more than 17% of its gross domestic product on healthcare, our global ranking in comparison to other health systems is deplorable. There is no future for a poorly ranked healthcare system that drives us to a frightening degree of deficit spending.

Our fee for service approach coupled with fear of malpractice claims undoubtedly generates unnecessary procedures and resultant expenditures. It’s also a fact that 19.1% of Medicare patients are readmitted within a month of hospital discharge. 56% percent are readmitted within 6 months.

Approximately half of the patients with chronic conditions like heart disease or asthma actually either miss doses or don’t take their medications as ordered. Non-adherence to medical regimens accounts for a great deal of wasted spending and potentially avoidable costly admissions. And furthermore, ignoring the challenges of caring for our burgeoning elderly population is as unrealistic as setting off on a cross-county trip with only enough money in your pocket for a single tank of gas.  Be assured that you are not going to get far.

The real question is how and where should we begin.

Essentially we have two distinct options. The first is a purely economic solution — slicing and dicing the overall healthcare delivery system — cutting back on payments to physicians and hospitals while limiting access to costly treatments and medications.  While overall expenditure reduction is assumed to be immediate… the prolonged negative consequences are both far-reaching and unsettling. The second option includes novel strategies designed to improve care coordination, prevention and personal engagement in health and well-being. 

Let’s focus our attention on a novel care coordination strategy.

Let’s begin by getting back to our roots – or where our nation’s healthcare actually began.  Hospitals were originally founded by community volunteers who were intent on taking care of their neighbors in need. In a similar manner, our patient-centric strategy is based on what we refer to as a Community Care Network – a CCN.

I know what you’re thinking — we’re just adding another layer of cost and complexity to an already overburdened system. I assure you that’s not the case.

The CCN is actually a cost-effective extension of a community hospital that operates seamlessly with other local health agencies to support the ongoing needs of its patients through physician-directed coordinated care. Consider it an all-encompassing healthcare system without walls — or a patient centered medical home on steroids. We actually like to refer to it as a patient-centered medical condominium.

The CCN is effectively run by the hospital.  It’s comprised of a physician-directed interdisciplinary team of nurses, counselors, social workers, nutritionists and ancillary support personnel. The CCN’s mission is to provide the highest quality continuum of compassionate, outcomes-based, patient-centered, culturally-sensitive healthcare. Each patient’s choice is respected, and our quality measures are outcome, rather than process-based.

We adhere to a “no-discharge” policy. We will not abandon people in a sea of seemingly overwhelming healthcare challenges where they struggle to stay afloat.

Our commitment extends beyond the confines of disease management — addressing socioeconomic, educational, psychosocial and behavioral factors, as well as each person’s adherence potential. Our quest is to identify and eliminate medical errors, care gaps and obstacles to receiving healthcare whenever possible. The CCN also focuses on reshaping healthcare behaviors and promoting early interventions to prevent the development of ambulatory care sensitive conditions (ACSCs) and unnecessary complications, hospitalizations or readmissions.

Now I know what you’re thinking.  It must cost a fortune to deploy the army of individuals needed to accomplish these lofty goals for a community! Surprisingly it doesn’t … due to the fact that we are engaging a rather unique workforce! Through an unprecedented collaboration between Meadville Medical Center and Allegheny College, pre-med students are engaged in a formal credit-based training program that enables them to serve as health coaches supervised by the CCN interdisciplinary team.

How is that possible?

The answer is rather straight-forward.  Students are formally trained by a faculty comprising physicians, a nurse coordinator, social worker, psychologists, nutritionists, an ethicist and even a healthcare attorney through a formal semester-long didactic interactive college course.

Upon completion, these extraordinary students begin a practicum by shadowing members of the interdisciplinary team and are thereafter progressively deployed to serve as health coaches within the community. Under team supervision, each health coach’s primary responsibility is to inspire and motivate our patients to become more actively engaged in their health and well-being. Health Coaches work with CCN health professionals to reduce what ultimately falls though the cracks and escalates into the realm of costly often overwhelming problems on many levels. Examples include missed appointments, medication reconciliation errors, misunderstandings and inability to adhere to prescribed health regimens.

In this CCN-based Health Coach model, everyone wins.

Our patients benefit from a reliable dedicated patient-centered continuum of care. Our physicians receive the support they need for helping to care for patients with a myriad of challenges in multiple domains. Our community realizes enhanced overall health and well-being. Our student Health Coaches benefit from real world experiences — one of the most important life-shaping determinant of success for our evolving healthcare workforce.

“Too good to be true,” you might be thinking. Too expensive to justify for the average hospital?

While these are good questions, we have great answers.

First, our dedicated healthcare faculty is not paid — they donate their time to our formal training program.  In fact while we only ask that they present for one lecture, often 5 or more of our faculty members work together for each class.

Next, our Health Coaches do not get paid either — they receive college credits for their participation in both the didactic sessions and practicum.  In effect, we are vastly expanding the workforce with minimal cost other than supervision!

Finally, we believe that the program cost can be justified by the overall savings generated by the CCN coupled with improved outcomes and the reduction of proposed penalties associated with excess readmissions.

In conclusion, this innovative hospital-based, culture-shifting healthcare strategy is effective, affordable and sustainable.  From a humanistic perspective, it is the right thing to do.

When properly implemented, it has great potential to serve as a  giant step toward radically reshaping our nation’s healthcare for this and successive generations.

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