Healthcare Collaboration: A Dream for All

With the recent celebration of Martin Luther King, Jr.’s birthday, we are reminded about his passion for the dignity of life and justice for all Americans.  He would have turned 83 this year; and if this had occurred, it would have defied the average life expectancy of  69.7 years for an African American male.  Revisiting Dr. John Eisenberg’s, former Director for the Agency for Healthcare Research and Quality’s 2000 post, I too wonder what Dr. King would think about parity, but also the manner in which healthcare is delivered today?

While there remains significant work to be done regarding access for the under and uninsured, do we not have a wealth of opportunity to level the playing field by inviting all Americans to engage in their healthcare experience?   By encouraging patients to express their preferences for the type/intensity of health care services they receive and the settings in which they receive them, perhaps we would see more people taking an active role in preventative health and not just responding to an acute episode.

Poised on the cusp of a digital health revolution, there have been significant advances in electronic and personal health records,  mobile phones and wireless technologies, text messaging, tracking sensors and social media.  Despite this gain, a recent hypertension study published by the Journal of American Medical Informatics Association, noted that a mere 26% of patients used personal health records (PHR) frequently.   And it was only the most frequent users of the PHRs that saw reductions in their blood pressure.  So, how do we change this?

In the recent Congressional Budget Office economic and issue brief, Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment, one of the recommendations for delivering high quality low cost services is to apply team-based care that includes face-to-face, as well as, telephonic visits by care managers. While these individuals by and large have been working with chronic frequent flyers, imagine having a care manager assigned by your insurance company who becomes your point of contact upon entry into the system?  They review your insurance coverage with you to verify that it is appropriate for your needs, aid in your selection of a primary care provider and establish expectations for your role in maintaining your health.  Maintaining your health could very well be the most important job of your life.  Similar to a performance review, the payer care manager would contact you on an annual basis to confirm that you are liaising with your medical home care manager, discussing your care plan and acting on recommendations.  In essence, they become your macro patient relationship manager.

Payer care managers will also be instrumental in maintaining open lines of communication with the care manager, also known as the micro patient relationship manager, assigned to you within your medical home.  The success of such a model would be perpetuated by the secure exchange of vital data via a health information exchange (HIE), thereby allowing both parties to remain up-to-date regarding your current status.  Medical home care managers will work with providers, practitioners and individuals to develop a comprehensive plan of care.  And by ‘working’, these individuals become responsible for educating patients about their outcomes and reinforcing the role that they play in determining them.  With a firm baseline and predictive modeling, patients will receive preventative health reminders, episodic management and transitional follow-up.  Removing the burden of information exchange with pharmacy and lab providers, specialty providers, ambulatory sites and long-term care providers will also facilitate this critical planning process.

A system that provides connected care to patients no doubt can lead to improved care – and therefore improved health –  which is nothing less than a dream for all.

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