A Primer on Managed Care: Multiple Chronic Conditions

The four elements of the system work in con- cert to provide Mr. Smith the best possible care, as follows: Upon Mr. Smith’s arrival at the emergency department, the electronic health record system (the sensor) alerts the MC3, which notifies an interdisciplinary healthcare team (diverse work- force), including his primary care geriatrician, pharmacist, nurse, and social worker. The emergency department physician sta- bilizes Mr. Smith with prednisone and inhalers (evidence-based care), the social worker identi- fies that Mr. Smith is no longer driving due to his cognitive impairment and notes that his wife is in the hospital for pneumonia (social determi- nants of care collected by the sensor and stored in the data warehouse). The pharmacist arranges for Mr. Smith to have automated mail refills of inhalers, ensures proper inhaler technique, and adjusts his dia- We believe such a centralized method of care coordination leads to greater equity within populations. betes medication while on prednisone. Addi- tionally, the pharmacist is informed of Mr. Smith’s cognitive impairment and understands the challenges this poses for medication adher- ence. Thus, the pharmacist checks with a social worker about the current plan to ensure Mr. Smith has the necessary help with his medi- cations, and provides additional instructions regarding the prescription changes. The social worker also coordinates Mr. Smith’s transportation for a follow-up appoint- ment with his geriatrician, evaluates and ad­ dresses any safety concerns regarding his safety at home alone, and arranges for Meals on Wheels to ensure he has access to food while his wife is absent. As part of the population health registry for people with COPD, diabetes, and a recent emer- gency department visit, Mr. Smith is sched-

uled to receive a follow-up call by a nurse. The nurse checks on his breathing, daily blood sug- ars, and nutrition, and knows he is being sup- plied with Meals on Wheels and that no meal adjustments need to be made for his diabetes. However, through the SECBCI-provided care management, he already receives regular follow- ups in person and over the phone that the MC3 schedules and tracks. Instead of separate, unre- The MC3 tracks the percentage of patients with one or more emergency department visits in the past ninety days. lated follow-ups for individual conditions, the information from the emergency department visit is relayed to the nurse following up from the SECBCI, and inquiries regarding all condi- tions are made during a single follow-up call in the next week. Further, additional follow up is scheduled to evaluate his wife’s condition upon her discharge to determine whether her ability to care for her husband has diminished, and if so what additional services are required. The MC3 tracks the percentage of patients with one or more emergency department visits in the past ninety days, and therefore the emer- gency department visit represents a significant event in his care. Through review of Mr. Smith’s ongoing care use and costs, the MC3 analyst team is able to assess his care’s effectiveness, and strategize with the nurse and social worker regarding any additional care needed. The MC3 team can review whether or not Mr. Smith fills his prescriptions, if he routinely misses appointments, or if he has repeated emer- gency department visits—patterns of care use that warrant consideration of further cogni- tive decline, relapse of depression, or inadequate social support. If any of these were present, the MC3 nurse would contact the geriatrician to ensure the issues have been identified and there

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