When leaders at Ochsner Medical Center took a hard look at its approach to chronic disease management 3 years ago, they realized that not only did it have a large population of patients at risk for or with hypertension (40%), but that of those diagnosed, the success rate of treatment was lingering at 30%.
“We recognized that the way we’d been doing health care the past 20 years is not how we’ll be doing it in the next 20 years. We have a lot of lives at risk [with chronic conditions] and reimbursements are declining on a monthly basis. Something had to change,” says Christopher J. White, MD, MACC, MSCAI, FAHA, FESC, FACP, Medical Director of Value-Based Care and System Chair for Cardiovascular Diseases.
Launched in 2016, under the direction of Dr. Richard Milani and the Ochsner Innovation (iO) team, the New Orleans–based health system’s digital hypertension program, a centralized and standardized approach to chronic disease management, has improved care, resulting in 79% of patients now reaching goal blood pressure in 180 days.
In a recent NEJM Catalyst Insights Council survey on the topic of chronic care models, only half of respondents, a qualified group of U.S. executives, clinical leaders, and clinicians at organizations directly involved in health care delivery, call their organization extremely or very proactive in their care for patients with chronic conditions.
With 6,000 patients opted in, the digital hypertension program uses the electronic health record system to flag patients who could benefit from closer monitoring. That panel is assigned to a “bunker of 6 PharmDs” — and wellness coaches — who use telehealth, texting, email, and remote monitoring to interact with patients at all risk levels. Success is based on improvements in the patient’s health as well as medical literacy, adherence to medication, and activation indicators.
Though the program is financially reimbursable because of the confines of the fee-for-service model, the benefits have made it worth investing in as it improves outcomes and “starts to solve the access problem,” White says. Patients are well attended to — some as much as 3 to 4 times a week — without filling a physician’s schedule (leaving room for new patients) or the emergency department. Also, patients are more satisfied and avoid costly hospitalizations and readmissions, White says.
Our survey finds that 76% of respondents say their organizations rarely or never use telehealth/telemonitoring tools to care for patients with chronic diseases, and of those that do, nearly half find them ineffective.
Stanley J. Szefler, MD, Research Medical and Director for the Pediatric Asthma Research Program at The Breathing Institute at Children’s Hospital Colorado in Aurora, says stronger use of telehealth/telemonitoring and remote monitoring is currently making its way into his organization. “You first need to build an infrastructure to be able to coordinate the care, pull the pieces together, and then put the right resources in place” before these methods are effective, he says. “That’s how we are evolving here.”
The Breathing Institute developed an asthma management program to centralize clinical care and to “put current care under the microscope” to better understand the social determinants of health that prevent better asthma care. They look at how prescriptions are filled, why routine appointments are missed, why there is overutilization of the emergency department, and more. Szefler says remote monitoring, when it is rolled out, could help make some of this information less confrontational. “Instead of asking ‘what are you doing?’ we can show them what they are doing, such as around inhaler medication usage through electronic medication monitoring, and what can be done differently,” he says.
Although Children’s Hospital Colorado also follows a fee-for-service model, senior leadership is placing an emphasis on preparing for population health management through chronic disease management.
The same is true at Christiana Care Health System in Newark, Delaware, which has given clinical leaders “financial room” to address chronic disease management, according to Roger Kerzner, MD, Clinical Director for Specialty Services for the Medical Group and Associate Service Line Leader for Primary Care and Community Medicine.
“The chief focus at Christiana Care is to continue to improve on the good work we are providing to our patients now that will be sustainable in the future and will benefit our long-term financial health,” he says.
Christiana Care is working to standardize care for hypertension, diabetes, substance abuse, COPD, and heart failure. The aim is to create a tight collaboration between primary and specialty care, which is bound to require culture change. “It’s a very different kind of care delivery model than physicians have been trained to provide,” Kerzner says, pointing to a nurse-run protocol currently being developed. Nurses would manage and adjust medication for hypertension patients without always needing to rely on a physician.
Christiana Care also wants to move chronic disease management into the community and offer “the same service in a different location,” helping to address social determinants of health and health inequity.
While remote monitoring has been successfully deployed at Christiana Care, the technology has not been fully implemented throughout the health system. “The first step is to create a system in which we can capture the full value of remote monitoring,” Kerzner says. “Once this is established, we can take advantage of this technology to improve chronic disease management.”