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ACP 2019: Chronic care patients improve through teamwork


Key functions that practices must provide to patients in order to better manage chronic conditions

team-based care, patient care, chronic disease

©Luis Louro/Shutterstock.com

Patients with chronic conditions such as diabetes, COPD, and congestive heart failure are some of the most challenging for physicians to treat. 

The good news is that there are proven strategies for physicians to help patients improve their management of these difficult conditions, said Edward Wagner, MD, MPH, an internist and director emeritus for MacColl Center for Healthcare Innovation, Kaiser Permanente Washington Health Research Institute, Seattle, Wash.

Practices that have succeeded in improving the care of patients with chronic conditions have done it by transforming their workflows and enlisting the entire staff into the care team. This ensures that each staff member to work “at the top of their license,” Wagner said. 

This team-centered approach has care benefits for patients, but it is often uncomfortable for physicians who are used to being in charge and responsible for all aspects of patient care.

“They use the practice team in ways I suspect that many of us would be uncomfortable with,” Wagner said.

“Making these changes actually reduced their burnout, not increased their burnout, because they were able to reduce their responsibility and share responsibilities with their teams,” said Wagner, who presented a lecture on managing chronic conditions at the American College of Physicians conference in Philadelphia.

“This is now the responsibility of staff, not just physicians,” Wagner added.

Wagner said patients with chronic conditions share these common needs:

  • Drug therapy that meets their goals.

  • Effective support so that they can competently manage their illness. 

  • Preventive interventions from physicians and clinicians when appropriate.

  • Evidence‐based monitoring and self‐monitoring to detect exacerbations and complications early.

  • Follow‐up tailored to severity, and more intensive management for those at high risk.

  • Timely, well‐coordinated services from medical specialists and other community resources.

In the 1990s, Wagner said, chronic conditions were not particularly well managed, as quality metrics went largely unmeasured and a large percentage of physicians did not have their conditions under control.  Furthermore, office staff was barely involved, and treatment standards were not standardized. That changed with more research and emphasis on new models such as the patient-centered medical home.

Wagner said that there are key functions that practices must provide to patients to better manage chronic conditions. These include:

  • Population management: Staff uses data to identify and close care gaps by reaching out to patients with conditions judged by performance metrics.

  • Planned care: A planned visit is an encounter that uses patient data, team and practice organization, and decision support to ensure that patients receive the care they need.

  • Self-management support: Since managing chronic conditions often requires patients to change daily habits, practices must work with patients to create plans and help link them to services such as health coaches, nutritionists and more. Setting goals and documenting progress is key, Wagner said.

  • Medication management: the goal of this function is to treat to target using protocol‐based prescribing and monitoring of adherence and outcomes. Medication reconciliation is viewed as a critical intervention, Wagner said, and the process begins with a medical assistant reviewing meds before every visit. Pharmacists also have a role to play, Wagner said.

  • Referral management: Staff provides assistance and support to link patients to the specialists and community services they need to adhere to their treatment plans.

  • Care management and follow-ups: Staff stays in regular contact with patients between visits in order to address their concerns and questions. Patients with greater care needs may require more intensive monitoring.

  • Behavioral management: Primary care and a behavioral health team must form an “integrated care team” and share accountability for the whole health of patients with behavioral health issues such as chronic depression, addiction and other conditions.

Wagner said that this model is proven to improve patient health and boost quality metric performance. The next step, Wagner said, is for specialty clinics to work on transforming their models to make them more compatible with their primary care brethren.

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