Physician Information From The Patient’s Care Manager

Long gone are the days where a small practice can afford to have an onsite case manager.  Aggressive cost cutting, defensive medicine, and other pressures continue to pull at the budget for running a practice for most physicians.

At the same time, the value of a nurse or pharmacist to work with the patient to coordinate care, provide medication reconciliation, and answer clinical questions has been demonstrated in numerous settings.

Of course, most patients with chronic illnesses like diabetes or asthma or even cancer often have a disease manager or case manager provided to them by their employer through a population health management company or their health insurer.  So, if this work is being done, what should be done to coordinate this care with their PCP or their specialist?

I’ve never seen it done when which prompts several questions:

1. What information a physician would want to receive?
2. In what format?
3. And, with what frequency?

Here are some of my ideas:

1. A copy of the care plan that’s been created for the patient based on evidence-based guidelines.
2. A list of any gaps-in-care that have been identified and discussed with the patient.
3. Any assessment that has been made of the patient’s risk level along with information about how that assessment was made – i.e., claims based modeling versus nurse based assessment.
4. Information about the patient’s Rx adherence and/or barriers to adherence.

But, what about things like:

1. Benefit information.  Does the physician want to better understand any network limitations, Centers of Excellence, or other clinical pathways to be followed?
2. mHealth.  Does the physician want to understand any apps that the patient is using and how that data is being incorporated into the care plan?

The more challenging question is how to deliver this information in a valuable format.

1. Direct mail seems slow and difficult to manage.
2. Faxing seems quick but an outdated modality.
3. Secure e-mail could work, but I don’t think most physicians want to have multiple secure e-mail accounts to coordinate.
4. A physician portal could be efficient, but probably only if there’s a concentration of patients at that office that use the same care management company.
5. Integration into the EMR is probably ideal, but this is a challenge with all the different vendors out there.

The other question is frequency.  Should this data be provided after every interaction?  Should it be batched and provided weekly or monthly?

And, in the case of print materials, should the data be sent per patient or aggregated per physician?  It would seem overwhelming to get one letter with data on 20 patients, but on the other hand, having 20 letters would allow the information to be more easily filed per patient.

This type of coordination is critical as we move from a fee-for-service to an outcomes-based environment where care coordination is more important than ever.