Engaging the Chronic Care Patient

Frustrated and noncompliant patients can lead to increased healthcare costs. Through remote monitoring, video conferencing, and nurse navigators, health systems and hospitals are tapping into the needs of patients facing an array of chronic conditions – and lowering their cost of care.

This article appears in the November issue of HealthLeaders magazine.

Emily Lieb, MD, medical director of Bon Secours Health System's Care-A-Van program regularly goes into the community to connect with patients. She and a nurse colleague and medical assistants drive to sites in Virginia on scheduled days in the hospital's mobile health clinic to provide free, urgent, and preventive care to patients who are uninsured and might not have seen a family doctor for a while. Their patients have chronic conditions and have lost track of their own medical history.

A typical patient is one who steps inside the van with a nagging cough and asks to be checked for bronchitis. After an initial examination is done, the diagnosis of bronchitis is confirmed, much as the patient suspected. But there's more to it than the patient realized. "Did you know your blood pressure is high? And you may have other complications?" The patient is surprised but agrees to follow-up care with a primary care physician.

By providing that convenient and unassuming healthcare presence in the van, "you can work hard to reverse their problems," Lieb says. "You have dodged a bullet. The patient is empowered in that situation to change things and is very happy about it."

The health provider's van makes at least 400 visits a month in remote areas of Virginia where the patients may lack transportation. Bon Secours is a $3.3 billon not-for-profit Catholic health system based in Marriottsville, Md., that has 4,400 beds among 19 acute care hospitals in six states.

The medical director of the Carolina Advanced Health medical practice in Chapel Hill, N.C.,Thomas Warcup, MD, DO, FAOBFP, looks at a monitoring screen and listens to a patient's rundown of ailments. The doctor is glad to hear from the patient because, like many who call in through the practice's telemonitoring system, this patient was expressing frustration with his previous experiences in healthcare and hadn't seen a doctor for a while. To engage such patients, the Carolina Advanced Health program is involved in a care partnership with BlueCross BlueShield of North Carolina and the University of North Carolina Health Care.

After months of telehealth talks, and tapping into self-monitoring programs through the practice's advanced technology, these patients are finding something unusual in the sometimes arduous journey of taking care of themselves: They are actually enjoying it, Warcup says.

Lieb and Warcup, in different ways, are making inroads in the care of patients with chronic conditions who have been among the most reluctant partakers in healthcare. Ironically, they are among those most in need. In the process, these providers are developing improved engagement, loyalty, and satisfaction among the most disenfranchised patients.

Patients with chronic condition are the "heaviest users" of healthcare services, according to Medicare studies.

In a report this year, the Centers for Medicare & Medicaid Services stated that about one in five Medicare beneficiaries was admitted to a hospital in 2010, resulting in costs of more than $100 billion. Chronic care is the crushing fiscal blow: Among the 14% of beneficiaries with six or more chronic conditions, more than 60% were hospitalized and accounted for 55% of total Medicare spending for hospitalizations.

"Beneficiaries with multiple chronic conditions were more likely to be hospitalized and had more hospitalizations during the year," according to CMS.

Yet these patients are often frustrated with their healthcare or are noncompliant, leading to increased costs.

"Some people are just dissatisfied with the throughput process; some are unhappy with their providers, have a misunderstanding of their disease, and just haven't been able to break through their static inertia," says Warcup. "Certainly, when they come to see us in our practice, maybe they haven't seen anybody in a while."

A major focus for his practice, says Warcup, is to help patients "get motivated, or stay motivated, when they hadn't been before. Sometimes they had felt dictated to, or never understood their disease well enough to stay motivated."

Physician practices and healthcare systems are focusing on various engagement strategies to help patients become more empowered in their care and also leading them toward greater patient satisfaction through technology or improved communication in chronic care management.

Through remote monitoring, video conferencing, nurse navigators, coaches, and various educational programs, healthcare systems and hospitals are tapping into the needs of patients facing an array of chronic conditions, from high cholesterol, asthma, and diabetes to congestive heart failure and depression. That's not all: They are using remote apps for "real-time" care so they can adjust medication when needed, schedule appointments quickly, and effectively monitor their patients, ease their concerns, and thwart potential hospital admissions or readmissions.

Medical groups and hospitals are asking patients not only about their clinical needs, but also about their social and economic conditions—beyond the scope of their disease—to tap into potential care needs. Physicians are changing their schedules to make it more convenient for patients to see them. Hospitals are also talking to patients about follow-up care, well before they are discharged from their rooms.

With a growing older population and those with chronic diseases, hospitals have little choice but to improve coordination of care for chronic ailments, says Don Bignotti, MD, senior vice president and CMO of CHE Trinity Health based in Livonia, Mich. Like other healthcare systems, CHE Trinity Health is concentrating on "chronic disease management to provide for the needs of the community," he says.

CHE Trinity Health is forming an "intense cardiac improvement program" and a "diabetes collaborative" that are included in a medical home care structure, Bignotti explains. In late 2012, Trinity merged with Catholic Health East, creating a health system with 84 hospitals, 89 continuing care facilities, plus home health and hospice programs serving residents of 21 states.

He says it's important that patients are engaged to improve their chronic conditions, and patient satisfaction also plays a role. "If patients are engaged and moving forward and their quality of life improves, we also believe they will become more satisfied in their care."

Improving patient engagement and loyalty is naturally linked with enhanced hospital processes of care, Bignotti says. By focusing on heart failure, for instance, Trinity, prior to the merger, reported a reduction of 30-day Medicare all-cause heart failure readmissions from 19% to fewer than 16.2% in a six-month period. Essentially, technology sometimes takes a back seat to improvising a care path. "It's about teamwork and a lot of interventions," Bignotti says. A major impact results from a simple formula: hospitals working with primary care physicians to ensure follow-up appointments for patients, he adds.

"For the patient, it's the experience in the sense of being connected and holistically involved in care," adds Mary Ellen Benzik, MD, CMO of Physician Network Services for CHE Trinity Health. "You have to have a holistic view, having the system surround the patient in a coordinated way. The patient says it feels different."

Success key No. 1: Technology, flexibility

Warcup knows the patients he sees at Carolina Advanced Health had been reluctant to see their doctors, and many said they were dissatisfied with their care. "They never understood their disease well," he explains.

Working with BlueCross BlueShield of North Carolina and the University of North Carolina Health Care, CAH has reached out to patients who hadn't seen their primary care physicians for at least a year, asking them to give CAH a try. Within two years at CAH, Warcup has seen these patients transformed, especially in their attitudes about seeking care.

Technology and flexible staff time have improved patient engagement and satisfaction.

Warcup says he emphasizes team-based care, and "on-time" electronic information for patients, with increasing use of telehealth. The practice focuses on care for chronic conditions, such as diabetes, hypertension, high cholesterol, congestive heart failure, coronary artery disease, and obesity.

The care team is robust, and includes physicians, specialists in internal medicine, a psychiatrist, physician assistants, behavioral specialists, nutrition/health coaches, clinical nurse managers, and social workers. By concentrating on chronic disease management, the team effectively reduced the number of patients seen by each physician, from 3,000 to about 1,300, Warcup says. That focus on chronic care has led to a 10.5% reduction in hospitalizations among the group's patients.

"We use motivational type interviewing: 'What's the optimal health for you? What does it look like?' We try to spend a lot of time educating [patients] on their disease and showing them different technologies to help them manage their disease. If they say, 'The goal is to be around and see my granddaughter or daughter get married,' we turn it around and say, 'Here's your goal, not my goal. Your goal can be achieved if we do this.' It helps them stay motivated when they hadn't been before," he says.

Within one year, patient satisfaction scores reached 95% and 100%; that was especially unusual, Warcup says, because many of the group's patients weren't welcoming of medical care. More than 100 patients were polled.

"Some [patients] haven't seen anybody in a while," Warcup says of those who had stopped seeking medical attention. "We spend a lot of time educating them about their disease, and we show the different technologies we have to manage their disease. We have expectations that they are part of the team. We use that language constantly: You are part of the team."

Carolina Health Alliance also relies on an electronic medical system that gives its physician an accurate real-time view of patients' conditions. The system checks on the current status of patients using a color-based system. For instance, diabetics' color coding might be graduated by intensity of need with red, yellow, or green defining the severity of their current condition.

On-site lab testing is available and on-site pharmacists work with patients to review medication. The practice also uses smartphone and Web-based programs that allow patients to monitor their diabetes, so "we are engaged, not intrusive," he says.

As they evaluate patients' chronic conditions, Carolina Health Alliance looks at patient psychological and social conditions as effects on their care. It doesn't stop at the doorstep of clinical needs. "With our patient connect surveys, in the comfort of their own home, they can respond to screenings for depression, tobacco and alcohol abuse, and domestic violence," Warcup says.

Flexibility in hours also figures prominently in patient satisfaction. The medical offices open at 7 a.m., stay open at lunchtime, and include two nights with evening hours and half days on Saturdays. Appointments can be scheduled within 48 hours.

Overall, Warcup says that the "patient has a real appetite to understand why we do the things we do." And the message to patients is: "Ultimately, it's your decision and what we do is based on your goals."

Success key No. 2: Constant reminders

Usually, patients are given instructions about medication and taking care of themselves as reminders before being discharged from hospitals. The 174-bed Florida Hospital Celebration Health in Celebration, Fla., doesn't just ask questions or give reminders to patients when they are leaving.

At FHCH, the scenario seems more proactive: Patients are given reminders about their follow-up care while they are still in the hospital, days before discharge. The reminders are shared with friends and family members, too, with the approval of the patients. The staff asks patients questions about areas related to the Hospital Consumer Assessment of Healthcare Providers and Systems.

It is important that discharge planning begins early, says Monica Reed, MD, CEO of FHCH, which is part of Florida Hospital, a system that includes eight campuses serving the greater Orlando area. Nurses work with patients days before discharge to go over their care plans, medications, and what's needed for follow-up care, Reed says. Too often, "patients don't know what their medical diagnosis is, they don't understand the medication they are using, they don't make it to the next doctor's appointment after discharge. And then they end up back in the hospital with the same problem," Reed says.

The hospital ensures that patients receive educational plans gradually, says Patty Jo Toor, RN, OCN, MSN, the chief nursing officer for FHCH. "We want to be sure that patients aren't bombarded," she says. Hospital officials want the patient to have enough educational material to begin taking control of their care. Heart failure patients, for instance, are taught generally about the disease and what it means for them personally: the foods they should eat, what kind of exercise program they should have, Toor adds. To help patients understand their medications, nurses explain the prescription regimen and give them proper dosage before discharge.

The hospital tracked HCAHPS scores between 2012 and 2013. Nurse communication increased 13%, up from 70% to 79%; communication about medication increased 8%, from 59% to 64%; and discharge information scores increased 6%, from 79% to 84%. The overall rating improved 5%, up from 73% to 77%, and willingness to recommend jumped 16%, from 69% to 80%.

For CEO Reed, patient satisfaction stems from having patients engaged in their own care. "I think patient satisfaction is the beginning, then you have activation for the patient.

"At the end of the day," Reed adds, "you want to keep patients out of the hospital. So we want them to understand their disease process and to trust their care providers to help them in their disease process. I think loyalty is a substitute for trust: Do I trust these people with my health? If patients know we see the hospital as a place of health and one of healing, then we've done a good thing."

Success key No. 3: Life coach program

The emergency department is a place in the hospital where many chronically ill patients wind up because they don't have physicians of their own. As a way to connect—and stay connected—with these patients, Bon Secours Health System initiated a life coach program in which nurses and other personnel are assigned to help patients find medical care outside of the ED.

The life coaches can include nurses, technologists, or pharmacists. Two coaches are at each hospital location, where they reported an average of as many as 200 daily ED visits by uninsured patients without a primary care doctor. The average life coach sees about 10–15 patients a day.

From the outset of the program, Bon Secours staff would see all the patients who came into the ED and determine whether they needed a primary care physician, says Pam Phillips, senior vice president of mission for Bon Secours. Many of the patients did not have insurance. In some cases, they had ailments that didn't require hospitalization.

By connecting these patients with primary care physicians, Bon Secours improved their access to appropriate medical care, she says. In the first year of the program, from September 2008 to 2009, life coaches assisted 1,000 patients who had been using the ED for primary care needs, and only 12 returned. At least 60% of those who were helped haven't returned to the ED for chronic care but are instead receiving care in other settings.

Some of the patients "have acute conditions and eventually have to be admitted because it's so serious, or they come to the ED because they have an earache and it's not emergent but there is nowhere else for them to go," Phillips explains.

When they are directed to primary care physicians, the patients are integrated into the Bon Secours primary care employed network, or connected to a free clinic partner.

Clinicians ask patients about medical issues and, more important, about their social situation, if there's an issue at home, says Phillips. For example, if their electricity was turned off, they could receive a referral to the community agency to pay electric bills. "We try to address the social needs as well as the medical needs," she says. The life coaches also help patients fill out paperwork "because a lot of the people are entitled to benefits and they don't even realize it," she says.

The Bon Secours medical community connected 3,548 patients in 2012 to social services such as food, dental care, financial assistance for rent or utilities, or medication assistance.

"When a patient leaves they actually may have an appointment with a doctor at one of the clinics. A life coach calls them at home, reminds them of an appointment. If they don't have transportation, the coaches help them get it," Phillips says. In that way, it shows that patients can feel comfortable in knowing they have access to care they didn't know they had.

After meeting with the life coaches, 2,498 patients who didn't previously have doctors were scheduled for appointments with primary care physicians in 2012. Bon Secours also does follow-up calls to check on the outcome of the doctors' visits.

"The goal of life coaches is to establish community partnerships to better serve the economically poor with respect and dignity, and to improve access to primary care," Phillips says. "Helping people who don't have a doctor get established with their own physician is the first step in securing their health and consequently the health of the community."

Success key No. 4: Cooperation with competitors

In some cases, hospitals are teaming up to focus on chronic care programs impacting vulnerable populations. The cooperative arrangements include organizations that have been competitive with each other.

By having these organizational team approaches, however, hospital officials say they can improve access to care, target chronic conditions, and open the door for primary care physician referrals. In addition, they can reduce ED use and readmissions.

The 592-staffed-bed New Hanover Regional Medical Center works with Community Care of North Carolina, a community-based physician-led program designed to improve access to primary care medical homes for needy populations, especially for chronic conditions, says Scott Whisnant, director of government relations for NHRMC in Wilmington, N.C.

The collaborative effort "is attractive to the hospital, and we are seeing a better and newer way to treat this type of chronic disease," Whisnant says of chronic conditions. The community program has opened the door for more cooperation in which hospital physicians work with specialists within CCNC to find "best practices to treat patients [and] have care management by going to the home and making sure meds are taken correctly."

The NHRMC has a network of nearly 500 physicians from various hospitals to coordinate care, and serves a population of 1.2 million. Between 2007 and 2010, Community Care of North Carolina saved Medicaid nearly $1 billion, according to an evaluation by Milliman Inc., the CCNC stated. The coordination of care has resulted in a 20% reduction in readmission, compared to clinically similar patients who receive care, says Paul J. Mahoney, vice president of communications for CCNC.

When case managers review patient files and visit them, sometimes they find the root of their physical problems don't have anything to do with clinical issues but environmental issues that the hospital may not have spotted initially, Whisnant says. "A patient may feel they can't control their child's asthma. Then you find out the patient has a dog sleeping on the bed with that child. Does that have something to do with it?" Whisnant asks.

"Maybe a baby is having trouble breathing in the home, and then you find out they are scrubbing the floor with ammonia and the window isn't being raised" for ventilation.

Patient satisfaction scores in a 2013 report show that 82% of NHRMC's discharged patients said "yes," they would definitely recommend the hospital, compared to 71% of the North Carolina average and 71% of the national average. The figures were part of a survey of at least 300 patients from October 1, 2011, to September 30, 2012, according to Hospital Compare data.

In Illinois, the Chicago Medical Home Network focuses on a remote home monitoring program to more accurately identify at-risk patients and improve patient engagement and satisfaction. The network includes hospitals and dozens of clinics and physician practices that have agreed to cooperate and improve basic care for Medicaid patients, and they are linked through an Internet portal.

The participating Chicago hospitals are the 895-bed Cook County Health and Hospital system; the 160-bed Holy Cross Hospital; the 49-bed La Rapida Children's Hospital; the 319-bed Mount Sinai Medical Center; the 664-bed Rush University Medical Center; the 395-bed Saint Anthony Hospital; and federally qualified health centers.

Like some other hospital programs, the Chicago-based Medical Home Network, a collaborative of 12 hospitals and 110 team-based primary care medical homes, uses an electronic system to alert physicians when Medicaid patients are admitted, discharged, or use an emergency department, and the reasons why. MHN's secure Web-based portal, MHN Connect, also provides access to complete patient medical history to physicians throughout the world.

MHN goes one step further, says Cheryl Lulias, its president and executive director. MHN also operates a remote home monitoring initiative for hypertension and congestive heart failure patients at seven partner clinics.

Patients receive wirelessly connected technology that transcribes their medical readings in an encrypted fashion to a secure network, which, if necessary, triggers an alert to physicians. MHN provides the equipment free of charge to the patients. The equipment includes blood pressure cuffs and scales. Each device is battery operated and equipped with Bluetooth technology, which wirelessly transmit diagnosis readings to a cellular pod than then encrypts the readings and relays them to the portal.

From there, MHN facilitates data analysis, synthesizing real-time biometrics with the wealth of data available in its MHN Connect portal, resulting in actionable tools for chronic disease management.

The technology alerts help engage patients, and they are happier about the process, Lulias says. By enabling clinicians to monitor patients in real time, for instance, doctors are able to "mitigate the 'white coat' effect on blood pressure readings that occur during office visits, a temporary condition that can confound readings and lead to mismanagement of hypertension," Lulias says.

The remote monitoring program is one part of MHN's broader mission to drive better health outcomes for its target population. One of MHN's key performance indicators is for patients to receive follow-up care in their designated medical home within seven days of being in a hospital or having an ED visit. In December 2012, MHN reported 19% of patients were routed to medical homes within a week; and in six months, it was 23.4%, which Lulias sees as good progress.

"We're trying to reduce readmission, inappropriate hospitalizations, poor chronic care management, and preventable ED visits," Lulias says.

The personal communication between staff and patients has encouraged both, she says. "Through our efforts, we are working to engage patients, support healthier behaviors, and build healthier communities.

"We have made competitors collaborators for this initiative and have organized around a shared vision and purpose," says Lulias.

Reprint HLR1113-7

This article appears in the November issue of HealthLeaders magazine.