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The patient is at the center of collaborative care

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The patient is at the center of collaborative care

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NP from a MinuteClinic explains how she can be a part of causing better outcomes for chronic disease management as part of collaborative care

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NP from a MinuteClinic explains how she can be a part of causing better outcomes for chronic disease management as part of collaborative care

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diabetes mellitus (disease or medical condition)

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Collaborative Care and Chronic Disease Management

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Kristene Diggins, FAANP, CNE, NEA-BC, DNP, DCC, MBA, manager of professional practice at MinuteClinic, and Contemporary Clinic Editorial Board member, explains how advanced practice clinicians working in the retail-based clinic can work with primary care providers with regards to a patient's chronic disease management.

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1. Case management must change to collaborative care teams to provide what is required from the ACA, IHI's Triple Aim, and CMS (Joo & Huber, 2014).
2.  Collaborative care team research is limited and lacks standardization.
3. Early research results point to better patient outcomes, higher patient satisfaction and lower healthcare costs through collaborative care (Radwany et al., 2014).

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Screenshot of an excellent article on the history of case management

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Screenshot of an excellent article on the history of case management

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It is important to understand where case management has been in order to direct and envision where it is going.

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Amin, A. N., Hofmann, H., Owen, M. M., Tran, H., Tucker, S., & Kaplan, S. H. (2014). Reduce readmissions with service-based care management. Professional Case Management, 19(6), 255-262. doi:10.1097/ncm.0000000000000051

Berthelsen, C. B., & Kristensson, J. (2015). The content, dissemination and effects of case management interventions for informal caregivers of older adults: A systematic review. International Journal of Nursing Studies, 52(5), 988-1002. doi:10.1016/j.ijnurstu.2015.01.006

Bisiani, M. A., & Jurgens, C. Y. (2015). Do collaborative case management models decrease hospital readmission rates among high-risk patients? Professional Case Management, 20(4), 188-196. doi:10.1097/ncm.0000000000000098

Coyne, J. S., Hilsenrath, P. E., Arbuckle, B. S., Kureshy, F., Vaughan, D., Grayson, D., & Saygin, T. (2014). Triple Aim program: Assessing its effectiveness as a hospital management tool. Hospital Topics, 92(4), 88-95. doi:10.1080/00185868.2014.968488

Everett, A., & Lee, S. (2012). Community and public mental health services in the United States: History and programs. In W. Eaton (Ed.), Public Mental Health (158-165). New York, NY: Oxford University Press.

Joo, J. Y., & Huber, D. L. (2014). An integrative review of nurse-led community-based case management effectiveness. International Nursing Review, 61(1), 14-24. doi:10.1111/inr.12068

Kersbergen, A. L. (1996). Case management: A rich history of coordinating care to control costs. Nursing Outlook, 44(4), 169-172. doi:10.1016/s0029-6554(96)80037-6

Meek, J. A. (2012). Affordable Care Act: Predictive modeling challenges and opportunities for case management. Professional Case Management, 17(1), 15-21.  doi:10.1097/ncm.0b013e318234e7dd

Mittler, J. N., O'hora, J. L., Harvey, J. B., Press, M. J., Volpp, K. G., & Scanlon, D. P. (2013). Turning readmission reduction policies into results: Some lessons from a multistate initiative to reduce readmissions. Population Health Management, 16(4), 255-260. doi:10.1089/pop.2012.0087

National Council on Disability.  (2011).  Rising expectations: The Developmental Disabilities Act revisited.  Retrieved from National Council on Disability website http://www.ncd.gov/publications/2011/Feb14201

Naylor, M. D., Kurtzman, E. T., Miller, E. A., Nadash, P., & Fitzgerald, P. (2015). An assessment of state-led reform of long-term services and supports. Journal of Health Politics, Policy and Law, 40(3), 531-574. doi:10.1215/03616878-2888460

Radwany, S. M., Hazelett, S. E., Allen, K. R., Kropp, D. J., Ertle, D., Albanese, T. H., . . . Moore, P. S. (2014). Results of the promoting effective advance care planning for elders (PEACE) randomized pilot study. Population Health Management, 17(2), 106-111. doi:10.1089/pop.2013.0017

Rice, T., Unruh, L. Y., Rosenau, P., Barnes, A. J., Saltman, R. B., & Ginneken, E. V. (2014). Challenges facing the United States of America in implementing universal coverage. Bulletin of the World Health Organization, 92(12), 894-902. doi:10.2471/blt.14.141762

Trivedi, D., Goodman, C., Gage, H., Baron, N., Scheibl, F., Iliffe, S., . . . Drennan, V. (2012). The effectiveness of inter-professional working for older people living in the community: A systematic review. Health & Social Care in the Community, 21(2), 113-128. doi:10.1111/j.1365-2524.2012.01067.x

Wholihan, D. J., & Pace, J. C. (2012). Community discussions: A vision for cutting the costs of end-of-life care. Nursing Economic$, 30(3), 170-178.  Retrieved from https://www.nursingeconomics.net/cgi-bin/WebObjects/NECJournal.woa/wa/viewSection?s_id=1073744468 \

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Case management is at a critical point in history in providing quality care.  With the ACA and the IHI’s Triple Aim, a lot is being required out of the case management role.  Health systems are feeling the effects of the recent healthcare developments as well. Facilities with limited resources may likely be penalized for underperforming and yet, due to their limited resources may not be able to change as quickly (Mittler et al., 2013).  Undoubtedly, these places will need to rely strongly on collaborative care teams to maximize quality of care, better outcomes, and lower costs of services.  Facilities should have hope though.  No matter how limited their resources may be, research has shown that quality is more important than quantity (Bisiani & Jurgens, 2015).

The new emphasis on quality of care and prevention and management of chronic disease has not been lost on case management.  Shifts away from the individualized case manager role and toward collaborative care teams will become more and more the standard.  These teams will be better equipped to reduce readmissions, provide better quality care, and achieve the IHI’s Triple Aim (Joo & Huber, 2014).  Case management started in the United States and with the right persistence and focus, the United States will usher case management into an even brighter future of providing quality care, with better outcomes, at a lower cost through collaborative care teams.

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Pharmacist explaining how collaborative care increases patient satisfaction, betters outcomes and decrease provider burden

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Pharmacist explaining how collaborative care increases patient satisfaction, betters outcomes and decrease provider burden

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How Can Social Media Improve Patient Care

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Optimizing Collaborative Care in Patient Management

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Autumn Bagwell, PharmD, BCPS, clinical pharmacist at Vanderbilt Specialty Pharmacy, discusses the elements of an effective interdisciplinary collaborative patient management program.

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Topic: Case management and quality of care

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Topic: Case management and quality of care

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In order to provide better quality of care, case management is experiencing a shift away from individualized case managers to that of collaborative care teams.

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Primary care, OT, nursing, dentistry and more represented in this photo of USC students.

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Collaborative care improves quality of life

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Collaborative care improves quality of life

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Collaborative Care Nurses: Your Partners in Chronic Disease Management

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A Collaborative Care Nurse is a Registered Nurse (RN) who helps with the care of patients with chronic disease. They work closely with your Primary Care Provider to help manage stable chronic disease, and assist with implementing the care plan that has been laid out by your PCP.