Successful chronic care management is a challenge for many providers in the medical industry. Dr. Ezekiel J. Emmanuel, a chief architect of the Affordable Care Act, gave a speech at the 2018 AHIP Institute and Expo event in San Diego. In that speech he detailed five common characteristics shared by organizations managing chronic care. Those five common characteristics are identifying high-risk patients, embed care managers, empower care managers, active outreach, and educate patients.

Identifying High-Risk Patients

A high risk patient is someone with a serious medical condition who has a high risk of mortality. Conditions included under this are advanced cancer, heart failure, end-stage renal disease, and dementia. High risk patients are people who have multiple hospitalizations in the last year, or those residing in a nursing home. It can be difficult to treat patients whose insurance doesn’t cover specific medications. On the other hand, using empathy is one of the simpler-yet most effective- ways physicians can help high-risk patients.

Embedding Care Managers

Care management is defined as the application of systems, science, incentives, and information to improve medical practice and assist consumers and their support systems to become engaged in a collaborative process designed to manage medical, social, and mental health conditions more effectively. High-risk care managers must be out in patients’ communities. Several small studies have found that care management within primary care practices increases participation and enhances outcomes for patients with chronic conditions. Care management must be operationalized in a manner accepted by physicians and other care team members.

Empower Care Managers

Care managers deserve the right to have the same access to the data for their patients and should be able to make changes to the electronic medical record. It would be so much more beneficial for patients to have more doctors in one office so they can get all their care simultaneously. In addition, care managers would highly benefit from having access to a comprehensive, holistic view of each patient across the care spectrum.

This is the most effective way to identify and deliver the right care to individuals at the right time. One way to achieve this goal is by connecting technology in ways that breaks down walls and simplifies routine work, while enabling care managers to provide the human touch to patients in meaningful ways.

Active Outreach

Nationally, the trend is that patient loyalty to a specific doctor is declining. To maintain loyalty, doctors must reach out to members on a regular basis. This shows patients that medical personnel care about them. They are not just another face in and out of the office. Physicians are more than just their credentials, also. When physicians can embrace their different roles as mothers and fathers, as sisters and brothers, sons and daughter, it helps improve the connection patients are willing to have with their doctor instead of just getting in and out of the office. Patients will look forward to their visits instead of dreading going to the doctor.

Educate Patients

In addition, to improve care outcomes, physicians should spend more time with patients. Physician’s need more enthusiasm, motivation, and responsiveness to how patients’ are feeling and their needs. A patient’s understanding of their condition and the compliance with a doctor’s recommendations significantly affect the outcomes of patient health. Learning about their conditions means patients have the knowledge to undertake their treatments and with confidence and are likelier able to do it safely from home.