Frontiers of Engineering Reports on Leading-Edge Engineering from the 2009 Symposium (2010) / Chapter Skim
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Managing and Coordinating Health Care: Creating Collaborative, Proactive Systems--David A. Dorr
Managing and Coordinating Health Care: Creating Collaborative, Proactive Systems--David A. Dorr
Pages 103-114
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From page 103... ...
Thus fixing this system will require changing health care delivery to anticipate these needs, teaching and encouraging people and their families to seek help, and providing care that consistently matches medical knowledge. One possible "fix" is to add care managers -- specially trained nurses and social workers who focus on the broad health picture -- into primary care clinics.
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From page 104... ...
. With these "fixes," the health care system would address ongoing changes in a patient's health as the care manager, supported by HIT, focuses on proactive, collaborative, coordinated care.
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From page 105... ...
Figure 2 shows one potential course her post-hospital convalescence could take. Based on the hypothetical events listed on the left, in the next year, she goes home, appointments are planned, she attempts to resume her usual activities, sees specialists, has dizziness, chest pain, and some difficulties with control of her chronic conditions.
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From page 106... ...
In the usual system, she may call her PCP and, while waiting for the return call, her symptoms may worsen, and she may go to the emergency department. Upon seeing three of her specialists in follow-up, the lack of information sharing among settings and caregivers leads to new medications being prescribed but not remembered by the patient or family and not reconciled against her old list.
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From page 107... ...
In our studies, we first defined the goals of care coordination and then the crucial processes necessary to attain those goals. These processes are usually nonlinear, are initiated through comprehensive assessments, and require iterative follow-up on care plans and patient needs.
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From page 108... ...
. With limited time and attention, failures in communication are common, leading to errors and preventable negative outcomes, such as emergency department visits resulting from unreturned calls or unclear instructions.
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From page 109... ...
. The essential competencies of care managers include the ability to educate patients and motivate them to set and follow goals and care plans, as well as to communicate effectively with members of the team, the patient, and the patient's family.
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From page 110... ...
key process points can be defined and programmed to remind care managers about crucial tasks. Whereas electronic health record systems usually focus on individual clinic visits and work flow and relegate hundreds of items to unstructured to-do lists, in our example, HIT func tions can be adapted to help prioritize tasks by (1)
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From page 111... ...
Finally, summaries of the complex care and needs of patients are crucial to addressing emerging issues quickly and integrating the patient's history with anticipated care needs in one place. Figure 4 shows this summary mechanism, the FIGURE 4 Comprehensive summary sheet.
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From page 112... ...
In seven intervention clinics at Intermountain Healthcare, a large, integrated health-delivery system, we installed care managers, trained them, and adapted HIT over a period of two years to develop the protocols and system described above. Over the next four years, patients seen by care managers lived longer, had 24 to 40 percent fewer hospitalizations, and had significantly better control of their conditions than similar patients at clinics without care managers (Dorr et al., 2005, 2008)
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From page 113... ...
CONCLUSIONS Successful models of coordinated care that meet identified needs and improve patient health can be created by identifying gaps in current care systems, developing solutions that meet a particular patient's needs, and developing changemanagement processes. We have shown that one successful model is to use care managers to augment primary-care teams and HIT to remind care managers and clinicians about prioritized tasks.
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From page 114... ...
2007. Physician perspectives of nurse care management located in primary care clinics.
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