Care Transformation Center Blog

Three ways to improve chronic care management for high-risk populations

Megan Clark

High-risk patient populations—such as ED frequent users—are the ones that most need help getting to the right site of care. They suffer from high rates of chronic illness and have trouble accessing primary and preventive care, meaning they end up in the ED more often than they should.

We've identified three ways organizations can shift primary care from the ED to ongoing management at the right site of care.

  • Help patients effectively navigate the health system to receive the most comprehensive care possible
  • Improve communication to make sure providers working with the same patients can identify gaps and duplications to identify system-wide savings
  • Partner with community organizations to target the lifestyle factors underlying chronic disease and impact patients in their own homes and communities

Care managers direct to appropriate sites of care

Many organizations are now using navigators and health coaches to help their most vulnerable patients. At Bon Secours DePaul in Norfolk, Va., nurses referred to as "life coaches" meet with patients who do not have primary care physicians for 30-minute, face-to-face interviews. This interview covers both clinical and non-clinical needs, allowing the life coach to direct the patient to the most appropriate site of primary care as well as to any additional relevant resources such as transportation or housing.

Collaborate to scale solutions across patient population

While navigator programs can help target patients who have already entered the hospital, improving access to care must also involve collaboration with other providers. Sharing information, ideas, and best practices with other providers caring for the same patient population allows for cost-savings across the care continuum.

The Medical Home Network in Chicago, Ill. connects six hospitals, six FQHCs, and 733 primary care physicians who collectively care for 150,000 Medicaid patients. Providers share information with each other through a "virtual integrated delivery system" that allows patients to be tracked regardless of where they seek care.

Community resources extend care team reach

Hospitals and health systems should also work with community organizations to target the underlying lifestyle factors that put patients at increased risk for exacerbations of chronic conditions. By being more close to home, patients might be more trusting of these resources—and more likely to use them.

Sinai Health System in Chicago, Ill. has had great success in targeting pediatric asthma through peer coaches. Sinai carefully screens and trains community members to fill the peer coach role, who then go into the homes of families who have a child with asthma and educate them about the importance of avoiding exposure to secondhand smoke and the dangers of household triggers such as cleaning products, pests, and mold.

Sinai has seen a 13:1 return on investment in acute care spending on pediatric asthma for every dollar they’ve invested in the program.

Learn More

To hear more of our research, register for our upcoming webconference, "High-Risk Patient Care Management."