Patient, providers, insurer coordinate to address chronic disease [photos]

Informational teaching tools sit out on a table during a patient's appointment Monday, March 19, 2018 at CHI Memorial Family Practice Associates in Ooltewah, Tenn. By encouraging timely preventive and early interventional care, the coordinated care program works to keep people healthier and out of the hospital.


(total population)› PCMH practices show an average 2.4 times return on investment compared to non-PCMH practices› 4.7 percent reduction in inpatient admissions per 1,000; 0.6 percent reduction in ER visits per 1,000› Statistically-significant higher quality compliance scores on 10 out of 15 key Healthcare Effectiveness Data Information Set (HEDIS) measures.› Net savings: $1.6 million in TennesseeSource: BlueCross BlueShield

Managing multiple chronic conditions isn't easy.

For William Potts, 62, a typical day means juggling 15 different prescriptions, three blood sugar checks, a special diet, weight monitoring and keeping track of appointments with four different medical providers.

They're just some of the steps he takes to control his Type 2 diabetes, atrial fibrillation - an irregular heartbeat that affects blood flow - and other complications.

"It's hard trying to keep it under control," Potts said. "But the more you control it, the better off you are."

Potts struggled for more than a decade to manage his conditions, until health coach Karen Crowder, a registered nurse at CHI Memorial Family Practice Associates in Ooltewah, came into his life.

"I'm the person that gets involved when there is a barrier to care," Crowder said. "We gently remind and encourage people, because if you're not following what the doctor is wanting you to do, you're not going to be as healthy as possible."

Crowder's role is an example of a fundamental shift toward preventive medicine and population health that's occurring within the nation's health care system.

Names for the concept may vary - accountable care organization, patient-centered medical home, clinically integrated care - and differ slightly between providers, but the goal is the same: to better coordinate care.

Health care organizations recognize that gaps in patient care, particularly for patients with chronic illness, can lead to patient dissatisfaction, poor outcomes, unnecessary emergency room visits or costly hospitalizations.

This includes patients with uncontrolled diabetes, high blood pressure and high cholesterol, those who are overweight or obese, and those living with chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease and asthma.

"People might come in every year and a half and they're out of medicine. They're just out of control," Crowder said. "And then by the time they go a year or so, they've developed complications."

BlueCross BlueShield of Tennessee operates the largest patient-centered medical home program in Tennessee, with 29 practice partners, 346 locations, 1,837 providers and 323,510 members participating across the state, including Memorial, Galen Medical Group and Erlanger-UT Family Practice.

The insurer analyzes customer data to identify patients such as Potts who may have gaps in care. Then, the patient is referred to a health coach like Crowder, who is part of a care team embedded within a primary care office.

These practices showed an average 2.4 times return on investment compared to traditional practices, a 4.7 percent reduction in inpatient admissions per 1,000 and a net savings of $1.6 million in 2016, according to data from Blue-Cross BlueShield of Tennessee.

Memorial had established a similar program for its Medicare patients a few years earlier, but contracted with BlueCross' patient-centered medical home program in March 2016, which extended services to commercial and Medicaid BCBST patients in its primary care offices, as well.

"The goals were to increase the quality of care of the patients that are under our care, and get them into their physician's practice, because it's the PCP that they need to see, and they need to be the one that coordinates care," Crowder said.

For Potts, education was the biggest barrier.

With the direction of his primary care physician, Dr. Mark Crago, Crowder guides Potts through his care plan.

"I may order a treatment, and Karen can get that done in a meaningful way for the patients," Crago said. "She can spend much more time with a patient, say with diabetes, for instance. I can walk right down the hall and speak with her and get my patient much more information."

Crowder taught Potts how to better monitor his diabetes and diet, which he said is the biggest challenge.

"It gives you better knowledge of what's going on and what to look for to catch problems before they get too far," Potts said. "She taught me that when you take [blood sugar readings] in the morning, that's not always a sign that it's that low. You need to eat and take it two hours later, and that gives you more of an idea what's going on."

Crowder also assists Potts with his numerous prescription drugs.

"It's very labor intensive to keep his medication at the therapeutic level," she said.

Because of his heart condition, Potts takes a blood thinner, so his heart doesn't have to pump as hard.

Blood thinners help prevent stroke, heart attack and congestive heart failure - which twice landed him in the hospital - but also have dangerous side effects. For this reason, Potts needs monthly checkups to confirm that his blood is the right consistency.

The diabetes is also problematic. Aside from dietary restrictions, checking his blood sugar and expensive insulin injections, it causes nerve damage and poor circulation in his feet.

"I have neuropathy, and I don't have a lot of feeling from my knees down, and it gives me a balance problem," he said. "I have to wear compression hose - the stockings help because they keep the blood flow going."

Even with the stockings, Potts gets ulcers on his feet, which a wound nurse helps him treat. Otherwise, infection could spread to the point that amputation is necessary.

Recently, a bad sore on his big toe required antibiotics, but they interact poorly with his blood thinner.

"Antibiotics makes it go crazy, so I've been on a weekly check," Potts said, adding that he's grateful to still have all of his toes, unlike some other diabetics.

Marie Carver, a licensed master social worker, is also a member of Pott's care team.

Carver addresses everything from psycho-social issues to navigating health insurance and drug prices.

"It's overwhelming for that couple of minutes that the PCP is actually going to spend with them," she said. "As a social worker, I get used to a lot of these systems, and then a patient, they have no idea what they're even called. It's kind of maneuvering through the complex systems."

Carver said it can take a while to pinpoint problems, but sometimes care gaps occur from something as simple as lacking transportation to appointments.

Crago said having care coordinated and services under one roof helps increase efficiency and lower costs.

Not only are patients more likely to follow through with tests and treatments, because extra appointments and travel are eliminated, there are fewer repeat tests that occur when providers operate in silos.

"It's got to be less expensive than having people spread out," he said.

But most importantly, providers and patients both want and need to build a relationship, which takes time.

"If you know your doctor and your doctor knows you, they look at you as more than just a disease state, you're friends," Crago said. "That's truly ideal."

Contact staff writer Elizabeth Fite at efite@timesfree or 423-757-6673.