4 Keys for Success in Remote Chronic Care Management

Consider the following:

The sickest 5% of the population consume 50% of health care spending (Harvard Business Review, Managing the Most Expensive Patients, Jan-Feb 2020).

As cited in the same HBR article referenced above, authored by Dr. Philip Madvig & Dr. Robert Pearl from Kaiser Permanente, this sickest 5% consists of 3 cohorts, divided almost equally in total spend across the 5%:

The first third are patients that have chronic conditions such as diabetes, asthma, mental illness, etc. They require chronic disease management, see doctors frequently and may periodically end up in the emergency room.
The second third are those that experience one-time catastrophic health events.
The final third are people with severe medical conditions, such as heart failure, chronic renal disease, etc.

Out of these three cohorts, the only one where providers can substantively impact health care spend is on the first one. However, as Dr. Madvig & Dr. Pearl point out, this cohort is constantly changing, i.e., new people are constantly entering into the first third that weren’t there before, while others that were in the first one may move into the third cohort.

This means that chronic care management programs must include all chronically ill patients and not just those that are currently falling into the first cohort. And since these patients spend most of their time outside of the facility-based healthcare system, remote chronic care management is essential to treating the whole person, while being as cost-efficient as possible. This is especially true for provider organizations that are taking on risk in a value-based contract.

Since the traditional approach has primarily been facility-based disease management, supplemented by stratification tools, i.e., to use data & analytics tools to narrow disease management focus to only a subset of your chronically-ill, we are sharing four keys to success in implementing a truly impactful remote chronic care management program, which come directly from our real-world experience doing this day in and day out with tens of thousands of patients for more than five years.

1. Relationship Is 80% & Technology Is 20%

The last time that you received treatment for something from your provider, what do you remember most? Was it the technology they used? Or was it how they spoke with you, how they treated you and the relationship you had with your provider?

If you replied that it was the latter, you’re not alone. In a poll, conducted on behalf of the Health is Primary campaign, 89% of Americans said it’s important to have a relationship with their healthcare provider.

This is not to dismiss the value of using technology in your remote CCM program. We agree that technology plays a role in helping to address the challenges of scale and scope, and we have incorporated technology when it makes sense. But lost in the rush to use technology to modernize healthcare is how to utilize the most trusted relationship in healthcare—that between providers and patients. Technology is necessary but should support —not distract from—that personal relationship. Providers and health systems need solutions and partners that understand the need to leverage the trusted relationship to deliver on the care management efforts that support the whole patient.

Real World Example

Note: For privacy reasons, the identities of both the patient and SLH nurse care manager are not disclosed, but the event is a real event as recounted by one of our nurses after a consultation with one of their patients.

A Signallamp nurse care manager was working with a husband & wife that both had type 2 diabetes. They were both getting their prescriptions filled and both reported taking their medications. The husband was stable; however, the wife was having a recurring issue where her blood sugar was spiking every morning. The husband was very concerned and neither the husband nor her PCP could pinpoint why this was happening given that the wife was taking her insulin as prescribed. Our nurse care manager had been working with both of them for more than six months at this point and had formed a very good relationship with both of them individually. During their calls, it was not just a simple 20 min “check the box” consultation – they confided in her and spoke in detail about not just their healthcare but also their interpersonal relationships. Because of this, our nurse care manager was able to really probe with the wife and ask the hard questions around why the insulin spike was happening. What was the result? The wife admitted that late at night after they went to bed, she was getting up and snacking and then would go back to bed. Everything was documented directly in the doctor’s notes of their provider’s EMR (over VPN) and triaged accordingly. Once it was out in the open for discussion, the wife corrected the behavior and there were no more early morning insulin spikes.

Takeaway

The relationship matters. She was too embarrassed to admit this to her husband and her facility-based care team did not have regular enough contact to understand what might be going on and draw it out of her accordingly. But our remote nurse care manager had built such a rapport with her that she felt comfortable telling her the truth and getting it out in the open. This is not something that would ever show up in a data point in an analytics platform. It is not something a predictive model could predict. No App or text messaging system will ever get you this type of information. It only comes through the hard work of building a relationship with a patient that is based on human connection, not technology.

2. Use Your Remote Chronic Care Management Program to Take Burden Off of Your Providers

A common misconception is that implementing a Remote Chronic Care Management Program will overburden providers and add more to their workflow. When done properly, this could not be further from the truth. In fact, the exact opposite is true when implemented the right way, i.e., your remote care team helps to lessen the workload of your facility-based care team.

Just as one example, how often are your facility-based providers performing medication reconciliation (MedRec)? Consider the following numbers:

The average time it takes to perform a MedRec is around 15-20 minutes, but can take as long as 60 minutes (Ambulatory Medication Reconciliation and Frequency of Hospitalizations and Emergency Department Visits in Patients With Diabetes, ADA)

The average time a physician spends with a patient during an office visit is 17 minutes (Time Allocation in Primary Care Office Visits)

MedRec is essential to any chronic care management program, whether facility-based or remote. There are many complications that can be prevented simply by performing a MedRec, not the least of which is medication non-adherence. It is estimated that 10% of hospitalizations in older adults may have been caused by medication non-adherence (Adherence and health care costs). However, due to the limited time facility-based providers have with their patients, this is rarely done for a meaningful percentage of your chronic disease patients.

But a remote CCM program can easily perform MedRecs as part of their routine work with the patient. For example, not only do we perform medication reconciliation for 100% of the patients that work with our remote nurse care managers, on average we do them four times each year!

The same would apply to depression screenings (PHQ-9 & GAD 7) and/or enhanced fall risk screenings where patients are queried about their home environment.

The patients that we work with are so engaged that 53% of our calls are inbound calls from the patient. Your facility-based care team cannot handle that kind of call volume from your patients. But because your remote care team can be dedicated to engaging the patients telephonically and performing care management activities like MedRecs and screenings, not only does this free up this responsibility from your facility-based providers, but it also enhances the quality of care they can deliver to the patient as they now have access to this information documented right within the patient’s chart in the doctor’s notes.

Real World Example

Note: For privacy reasons, the identities of both the patient and SLH nurse care manager are not disclosed, but the event is a real event as recounted by one of our nurses after a consultation with one of their patients.

The Signallamp nurse care manager was working with one of her COPD patients. She had been working with the patient for several months now and had built very good rapport with the patient, learned about her lifestyle, her family history and she knew all of the patient’s chronic conditions and medications.

In order to help foster the human connection with the patient, all of our nurses work with the same patient panel every month, i.e., we do not employ a call center style approach. And because she had worked with that patient exclusively from the beginning, she noticed that this day the patient had a different inflection in her voice and sounded like she was wheezing.

The nurse took note of this. As she was performing a MedRec with the patient, when she got to the prescription inhaler, the nurse asked the patient if she was wheezing. The patient said yes. And then she asked if she had been using her inhaler. The patient said no. The nurse asked why not? The patient said the prescription was too expensive for her to fill. The nurse triaged the appointment and responded by reaching out to her physician’s office to get her some free samples for immediate use and her physician wrote her a prescription for an alternative inhaler that was much more affordable for her.

Takeaway

The basic blocking and tackling matters. Doing MedRecs and screenings and getting to know your patients – these things have a huge impact. Having an outstanding chronic care management program is much more about getting back to the basics than incorporating AI or Blockchain or some other buzzword. There is a reason Dr. Atul Gawande wrote an entire book on the importance of checklists, which is still currently the #1 best seller on Amazon in its category.

Sure, it is possible that data analytics could have revealed the pharmacy gap; however, pharmacy gaps are generally calculated using claims data, so you won’t know about the gap until 45-60 days later, which could mean that patient has a trip to the ER before you get to them. Also, technology would not have revealed the more important fact of why the prescription was not filled, not to mention the fact that it is hard to admit you can’t afford your medication. A patient may not admit that on a singular call about the missed prescription refill. In this case, the patient had a relationship with our nurse and felt comfortable telling her the truth – a truth that ultimately improved the patient’s health & quality of life, while also preventing healthcare dollars from being spent on an unnecessary trip to the ER.

3. Use Your CCM Program to Truly Leverage Social Determinants of Health (SDOH)

SDOH has been a buzzword for years now. And yet when you start to drill down into the details of any given provider’s SDOH initiatives, there is rarely that much substance to be found. A recent study published in the Journal of the American Medical Association, conducted across 5,000 hospitals & physician practices, found that only 24% of hospitals and 16% of physician practices are screening for all of the social determinants, such as: food insecurity, housing instability, utility needs, transportation needs and interpersonal violence. Even worse, the study found that one-third of physician practices and 8% of hospitals reported no screening at all. And even among those that are screening for social determinants, how many are doing this for all of their patients and truly leveraging that data to positively impact that patient’s quality of care and/or connecting those patients with Community-Based Organizations (CBOs)?

Contrast this with a Kaiser Permanente study which showed 93% of Americans feel their medical provider should ask about access to food and balanced meals.

There are several issues at play here, and they are not necessarily the fault of facility-based care teams. As mentioned above, facility-based care teams see the patients less often and have limited time with patient when they are in for their office visit, i.e., they are not designed to truly collect and leverage SDOH.

But a remote care team is (and should be) designed for this! Your remote nurse care managers should be directly speaking with your enrolled patients at a minimum of 20-30 mins per month (60+ mins for complex). Those patients should also be speaking with the same nurse care manager each time – this helps to form that relationship referenced in the prior keys to success. A natural course of this relationship will be that the patient becomes comfortable with your nurse care manager and will be more open with them as they ask questions geared toward uncovering SDOH. This goes beyond just filling in a questionnaire – it is truly getting to know someone and understanding what they need and meeting them where they are. Those nurse care managers can then respond appropriately (based on solid training) and connect the patient with CBOs when appropriate.

Real World Example

Note: For privacy reasons, the identities of both the patient and SLH nurse care manager are not disclosed, but the event is a real event as recounted by one of our nurses after a consultation with one of their patients.

One of our SLH nurse care managers was working with a patient that she believed may be food insecure based on their initial conversations. She also sensed that the patient may be self-conscious about this and avoided the topic for the first few phone calls until she felt she had a strong enough rapport with the patient that she could ask about it. As she began to question the patient, the patient admitted to her that they did not have transportation and that the only available food option was a dollar store that was within walking distance from her home. Our nurse responded by first reassuring her that this was OK and that she could help. She then pulled up the list of grocery items available at that dollar store and, in partnership with the patient, crafted a grocery list of healthy food options available to her that she could afford. Everything was documented directly in the doctor’s notes of their provider’s EMR (over VPN), so that their facility-based care team was aware of this and could discuss/respond appropriately the next time the patient came in for an office visit.

Takeaway

SDOH is more than a questionnaire. In order to actually leverage SDOH, you need to have ongoing (live) communication with a patient that allows you to form a relationship with the patient and act upon that individual patient’s needs as it relates to their social determinants of health. The only way to do this that is economically feasible and self-sustaining is through a remotely embedded nurse care manager model.

4. Profitability Does Matter, So Don’t Do It Alone

While you might be hesitant to hand over all of your remote chronic care management program to a partner, standing up a remote chronic care management program for all of your Medicare patients is unlikely to be economically feasible for most provider organizations. Providing services to a small fraction of your Medicare population and providing services to your entire population are completely different by an order of magnitude.

In order to do it at scale, you need to master the following:

Practice workflow:
Workflow is sacrosanct and there is no time for disruption or provider busy work. The remote care team must become a seamless part of your facility-based care team. You need to know what patients are likely to need between visits and, in most cases, be able to meet their needs without practice involvement. The business rules for addressing predictable patient needs like an office visit, a medication refill, or a referral need to be customized by provider preference for each of your practices.
Documentation:
To pass CMS muster, you must document each patient interaction in your EHR. It’s the record of truth. It’s exactly where your providers expect to see any patient encounter, in an easily digestible narrative format.
Identifying Eligible Patients:
Leverage your EMR to identify all eligible patients.
Enrollment:
CMS is crystal clear on the requirements for patient enrollment. If you cut corners here, providers may get negative feedback from patients that can derail the program before it gets going. Each patient enrollment needs to be highly scripted, monitored for quality, documented and followed by a letter to the patient confirming the same. We have found the best practice is to have a dedicated team for enrollment. For example, we have an entire enrollment department that has streamlined this process and works exclusively on enrollment every day.
Finding and Training Nurses:
If you’re enrolling 100+ patients per day (as we do for our health system clients), that’s at least one new nurse every week. You will need infrastructure in place that enables you to scale your hiring & onboarding process at this rate. When we do this for our health system clients, we do all of the hiring & training. If needed, we find nurses with complementary language or cultural skill sets. Our nurses are our employees, allowing us to hold each nurse to the highest quality standards.
IT Connectivity:
A remote workforce is not just about having a reliable internet connection. When managing a remote clinical workforce, IT challenges quickly multiply. You need a responsive and dedicated IT staff; otherwise nurse up-time and productivity will drop dramatically.
Managing Productivity:
You can’t financially sustain a remote care management program on the modest reimbursements without daily productivity and long-term patient retention. Don’t dare skimp on quality, though, or providers and patients will not stay engaged month after month.
Patient panels:
For a typical in-house care management nurse, you’re managing a handful of the neediest patients during an episode. Signallamp has scaled to the point where our nurses bill 300-400 patients in a month using our stress-tested platform for long-term engagement. Outside your office, patients aren’t as easy to reach. You’re working on patient time, and you will have to provide quality, consistency and value, otherwise they don’t engage. Further, when patients return home from an in-patient stay, you know exactly where they are. They’re home.
Billing:
Billing is never an afterthought. Patients don’t treat it that way, and neither should you. You need to have staff dedicated to resolving billing issues. We provide billing support included as a part of our CCM service offering. For our clients that elect for us to help them with billing, we create the ebill and the practices can either complete the transmission or we can post the charges on their behalf. For our other clients, we provide extensive reporting and documentation to support their billing team. With potentially thousands of charges per month, we are a ready partner in facilitating successful billing. Signallamp does not bill as a provider because we strongly believe 3rd party billing creates confusion among patients and represents a significant gray area in CMS regulations.

Final Takeaway

If all of this seems daunting and overwhelming, we humbly remind you that it has taken us over five years of only focusing on remote chronic care management in order to create a truly self-sustaining, scalable model.

If you already have a program in place, and think that you don’t need help, first ask yourself the following:

Am I enrolling 50%+ of my eligible population?
Am I performing medication reconciliation on 100% of the patients enrolled in the program?
Do 99%+ of my patients enrolled in the program receive a care plan?
Are my enrolled patients so engaged that 50%+ of the calls that take place are inbound calls?

If you answered no to most of the above, that’s OK! It does not mean that you are doomed and it certainly does not mean that you should scrap your remote chronic care management program. We would never advocate for this. We are here to help, not to take over.

We have a mantra internally: “Everyone needs more nurses”. We think everyone can agree that more nurses is never a bad thing and the world would be a better place if all provider organizations had more of them.

If you agree with us, the great part about our business model is that our nurses don’t cost you anything – literally nothing.

To repeat: More nurses to support your patients and providers at no out-of-pocket expense to you. Expanding reimbursements compensate you for the services we provide and scale at each of your provider locations. That’s new revenue without any new expenses. More support day-to-day AND a profit.

How do we do this at no cost? There’s no fine print. We simply share the fee from successful patient engagement. Our success is directly linked with your success, because without enough output and long-term retention our financial model collapses, so we are deeply incentivized to deliver on our performance metrics. We stand by our references on quality, but if you’re unsatisfied, you have a 90-day no-risk out.

We’ve already made the investments in a recruiting engine for talented remote nurses, built the technology infrastructure and perfected the workflows.

Give us a call

Sales: (215) 315-3510 General Inquiries: (570) 309-6095

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info@signallamphealth.com

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