LeadingReach News

Chronic care management has become one of the most important topics to healthcare organizations.  The move to value based care is going to require every organization to better understand how to manage chronic conditions.  Plus, things like SDoH (Social Determinants of Health) play a really important role in managing these chronic conditions effectively.

As we work to understand how chronic care management continues to evolve and mature, we sat down with Curtis Gattis, Co-Founder and CEO of LeadingReach and Dr. Jeff Bullard, MD, Chief Medical Officer and Chief Product Strategy Officer of Catalyst Health Group.  We ask them if we’ve finally turned the corner on proactively addressing chronic conditions and the state of chronic care management today.

They also share with us who is the best person to address the chronic conditions.  Is it the PCP?  Is it someone else?  Who’s on the team that’s needed to address chronic disease?  Plus, how does an overwhelmed PCP really address the SDoH challenges and what’s a model that works for addressing SDoH as part of chronic care management.

Check out the video below to learn more about how Dr. Bullard from Catalyst Health Group and Curtis Gattis from LeadingReach are working on chronic care management.

Tech-driven connectivity and collaboration tools empower primary care providers (PCPs) to shepherd patient care, while simultaneously empowering patients to make more informed and strategic decisions about their own health and care journey.

Health care, at its core, is an experience between patients and their health care providers. At worst, clunky technologies, operational processes, and reimbursement hurdles produce a fractured experience, usurping the attention that relationship-driven care needs. In an ideal scenario, those technologies, processes, and payments work seamlessly in the background, enabling the delivery of personalized care where patients are known and understood. And though even the right technology could never replace patient-provider interaction, it certainly can elevate it. Tech-driven connectivity and collaboration tools empower primary care providers to shepherd patient care, while simultaneously empowering patients to make more informed and strategic decisions about their own health and care journey.

As we continue to see new variants, subsequent delayed care and other pandemic curve balls, efficiency and optimization are the name of the game when it comes to meeting patient needs. In 2022, we’ll see more healthcare leaders focus on identifying and tracking critical conversion metrics (like their referral-to-appointment ratio and referral response rate) to ensure patients are getting the care they need rather than falling through the cracks, which happens 50 percent of the time with outdated communication processes that involve faxing.

As a result, we’ll also see more provider networks shepherding their patients towards more strategic partners and clinics and away from less responsive, less timely care. The traditional need for healthcare has not changed, even in the face of a global pandemic, but we will see an increased push to engage patients with their care, particularly when it comes medical conditions that require a team approach to healthcare.

It’s no secret that access to healthcare is a challenge for patients. And it’s becoming harder and harder for patients to get appointments with their PCP or the specialists they have been referred to for advanced care. Now more than ever providers and their staff are faced with a growing number of challenges that prevent or delay them from doing what they are all there to do: get patients in front of a doctor to determine how to get them well. One of the biggest villains in this story is the old fax machine. No matter the practice’s type or patient volume, there are so many ways things can go wrong with a fax-dependent process that is nearly impossible to standardize, has no real built-in accountability and is dependent on significant levels of coordinated communication. 

That’s why it’s vital for a practice to have processes, goals, and measurements that align with that core objective of both getting patients to schedule appointments and of course come in for their appointments. The easiest way to accomplish this is by managing the practice’s referral-to-appointment ratio, otherwise known as RTA. Aligning the staff’s objectives to optimize a practice’s RTA ratio means more patients are getting the care they need while simultaneously ensuring a practice’s financial health is secure. 

Traditional referral intake systems haven’t changed significantly in the past 30 years. Rather, they are still based on paper and fax referrals that often get lost in the shuffle of busy days and patient care needs. This reliance on old-school methods flies in the face of significant connectivity and communication adoptions that are being successfully leveraged in other industries. Between the barrage of phone calls and faxes flowing between provider offices, provider office administrators struggle to confirm patient information, locate missing labs and medical records, and keep track of inefficient and disruptive back and forth conversations to facilitate quality patient care. With disparate EHRs, scheduling software, and office procedures, provider networks have historically lacked a shared language and a standardized process too easily connect and communicate.

Under this traditional model, even in the best-organized offices, the administrative point person – the patient coordinator – deploys basic spreadsheets or a handwritten sticky note with limited sharing functionality to help make sense of the referral and health data chaos. This type of analog reporting takes hours, and the information and procedures get siloed into that individual patient coordinator’s workflow with no visibility or accountability. As this position is one of high turnover, the knowledge and process efficiency disappears with each resignation. These archaic methods often lead to patients slipping through the cracks and never getting the callbacks needed to close the loop and schedule appointments. While this is a huge issue for patients seeking critical care from providers they are referred to, this also has serious impacts on a full health system’s patient and revenue leakage. Ditching the old school model for streamlined technology can change the paradigm and enhance the care coordination process for both patients and providers.

To view the interview click below:

For South Texas Physician’s Alliance, social determinants of health referral has been a learning experience. The organization, which has joined providers across the country in efforts to address social determinants of health, knew the best solution was connecting patients to social services providers. A patient presenting with food insecurity needs a referral to a food pantry, or a patient with housing insecurity might need the help of a medical-legal partnership. But even with that strategy, organizations are facing an uphill battle, largely in terms of networking.

“There's just so much that we need to learn because it's just not an area in which medicine is used to functioning,” Sheila Magoon, MD, the executive director of South Texas Physician’s Alliance, told PatientEngagementHIT. But through an understanding of how to collect SDOH data, the pain points in social services referrals, and the types of technology and interpersonal partnerships the organization would need, South Texas Physician’s Alliance said it’s on the path to building out a strong community health network.