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