A Primer on Managed Care: Multiple Chronic Conditions

person so that a person with low health literacy, for example, may receive information via video or written text that is accessible and easy to com- prehend, while a more educated, highly engaged individual may do well with self-directed learn- ing modules, books, or other resources. Education increasingly is delivered via in­ teractive websites, portal-delivered handouts, video, and other avenues. Despite new technol- ogy, education for many people is best deliv- ered through a relationship-based approach using health coaches, certified diabetes educa- tors (CDE), and other human resources. These professionals can gauge body language, facial expressions, and other non-verbal forms of com- munication to help determine patients’ compre­ hension levels. Using teach-back methods to measure patient understanding can be very ef­ fective in making sure these education efforts achieve desired outcomes (Simmons et al., 2014; Barello et al., 2016). Clinical pharmacists are emerging as a valuable resource in the ambulatory setting to assist in condition management. Most states have regula- tions allowing collaborative practice agreements with physicians such that pharmacists, under protocol, can prescribe medication and bill for patient visits. In many settings, physicians and other providers diagnose the condition and set the treatment plan. The clinical pharmacist on the care team can then independently reach out to and visit with the patient to provide education and self-management support, and also titrate medications to achieve clinical goals. This approach fosters active management between physician visits, thereby reducing the time it takes to reach the patient’s clinical goals. Health plans and ACOs also have used phar- macists to help with issues such as medication access and adherence, which often are barriers for people in managing chronic illness. In col- laboration with health coaches, CDEs, and other Team collaboration: the role of the clinical pharmacist

educators, clinical pharmacists can be an effec- tive resource for supporting self-management. Teaching a person to self-administer medication, check blood sugar or other readings, and self- titrate medication in response to monitoring all are examples of skills that clinical pharmacists commonly teach (Greer et al., 2015). The promise—and challenges—of technology Increasingly, technology plays a role in chronic condition management and affects many parts of the care model. For instance, wearables (e.g., Value-based care models use an upstream approach to managing populations in order to avoid downstream costs. watches, heart-rate monitors, continuous glu- cose monitors, lenses) are providing new data inputs that in some cases feed directly into patient portals or other interfaces. Remote mon- itoring of glucose levels and blood pressure, for example, has become commonplace. These new data inputs are promising, but given the poten- tial volume of information, most systems strug- gle to appropriately filter that data and provide actionable information to physicians and other caregivers. Health systems must design policies and procedures to execute these programs effec- tively without creating “noise” for providers and other caregivers. Beyond wearables, new companies have emerged that combine remote-monitoring tech- nology and health coaches to guide patients toward positive behavior change. The most common examples are in managing diabetes and hypertension, but also they exist for other conditions such as chronic obstructive pulmo- nary disease and heart failure. In these cases, the person provides data via a glucometer, scale, or other home diagnostic equipment. That in­ formation is transmitted to a remote health coach or another professional who can provide

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