Looking Ahead at Tools for More Integrated Care Delivery

Moving from fee-for-service to population health delivery models will involve growing pains—and they’ve already started. But change is essential, and will require finding the right technology, practice management, and other tools to engage patients in their own care.

The American Journal of Managed Care

Many concepts for improving care delivery emerged during the panel discussion, “Integrated Delivery Networks and Adherence Intervention,” part of Patient-Centered Diabetes Care 2015, presented by and Joslin Diabetes Center.

“Medication adherence,” said panelist Paul Ciechanowski, MD, MPH, “is a form of behavior change, whether it’s lifestyle or self-management.”

Dennis Scanlon, PhD, professor of health policy and administration at Penn State University, served as moderator and invited the panelists to share how their current work related to the topic. “We want to get into how the future system is organization-driven versus virtually driven,” Scanlon said. “We’re thinking about how to connect patients across the continuum of care, and motivate them for self-management and, ultimately, adherence.”

New England Journal of Medicine

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Improved adherence starts with integrating behavioral health into the primary care practice, Ciechanowski said. The former University of Washington associate professor was part of a team that published a landmark study in the proving that a collaborative care model for treating depression and diabetes could improve patients’ measurements for glycated hemoglobin (A1C), low-density lipoprotein (LDL) cholesterol, and blood pressure, along with depression scores—all while saving money.Ciechanowski, a psychiatrist, now runs a company, Same Page, which is bringing this model across the country.

“It really fits hand-in-glove with ACO structures,” he said, referencing accountable care organizations. “It is a model that elevates the importance of behavioral change and the importance of physician extenders working as a team.”

At long last, he said, medicine is moving away from “blame the patient” and recognizing its own “clinical inertia,” which Ciechanowski described as medicine’s refusal to embrace more intense treatment when needed, refusal to deal with system redesign, and reluctance to “hold a mirror up to ourselves.”

Integrating delivery systems matters because no part of the system can “move the needle” on its own, said Todd Prewitt, MD, corporate medical director for chronic conditions at Humana. New defini- tions are needed in population measure, such as “healthy days,” or measuring fewer “medical days” for patients with chronic disease, which would be days when they cannot care for themselves. For Humana, large-scale events that involve providers and service agencies across an entire city are part of the strategy, he said.

Trishan Panch, MD, MPH, founder of Wellframe, is putting his experience working with London’s poor and chronically ill, plus his knowledge of technology, to use in developing tools to assist patients with self-care and monitoring. The technology is designed to bridge the gap between the visit-to-visit, week-to-week, and month-to-month contact with providers that Panch said works well in person or on the phone, but can’t be scaled to meet growing needs. This is especially true for those patients who will need to be monitored indefinitely. So far, Panch said, the technology has done well in trials and is moving into design phases.

The challenge for Ronald Tamler, MD, PhD, MBA, CDE, CNSC, medical director at Mount Sinai Clinical Diabetes Insti- tute, is that fee-for-service hasn’t had its last gasp yet; the demands of population health are rising, and patients—at least where he is—aren’t always willing to be handed off to a “team” member.

“Many of my patients have prediabetes and want to see the director of the Institute, and want to talk about how much broccoli to eat,” he said. “I’m thinking, ‘Is this a good use of our resources?’” But their insurers or employers are footing the bill, so it happens. The transition out of the fee-for-service world will not be easy, he said.

Overcoming clinical inertia—and forcing change—starts with measurement, Ciechanowski said. In the collaborative care model, the “secret sauce” is the weekly meeting in which the care team reviews each patient and sets goals, and members hold each other accountable. “Better-performing healthcare systems achieve 30% to 40% in getting A, B, and C—A1C, blood pressure, and cholesterol— on target. That’s one way we can look at a healthcare system.”

Better models of care are needed, he said, because if providers are “burned out” now, they must understand that more patients are coming—so a team-based approach is needed to handle what lies ahead.

But when it comes to measurement, Tamler said, some physicians question being evaluated at all; or they claim, “My population is different. I have sicker patients.” Ciechanowski said this is a big challenge, but that tools are being created that allow physicians to compare themselves with those with similar patient populations. Panch said when he practiced in London the evaluation models accounted for such differences; but, he added, “Of course, that’s much easier in a single-payer environment.”

Explaining the ineffectiveness of the current delivery system, Panch said that patients are the producers of their own health, while healthcare providers supply the “raw materials.” Thus, the experts have limited contact with the person most directly responsible for healthcare, which isn’t a great model for success.

Integrating care, Scanlon said, will mean bringing the patient new tools to offer access to better information, better behavioral health supports, and more motivation for self-care. Ciechanowski and Panch agreed, with Panch saying the key is to develop something lasting that patients won’t become bored with and “move on.” Tamler said there’s a lack of alignment between who wants technology and who needs it: while some parts of the population are receptive to technology and others less so, his organization’s research shows that the patients who are least receptive are the ones who most need to be engaged.

Deploying technology is more than just understanding the hardware, he said. It’s also understanding the cultural differences from place to place and group to group. Colleagues from Israel told him people text at 3 am and no one is bothered by it. “I was stunned,” Tamler said. “I told them never to do that.” Prewitt closed by mentioning regulatory limitations, especially on telehealth, which can be barred in some states if local medical societies disapprove. This limits national insurers, but most of all it hurts patients. “This shouldn’t be (what) we’re doing to the patient,” he said.

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