With the push for innovative care models focused on collaborative care and care management strategies, the re-tooling of clinical services and administrative processes must address gaps in care and reduce utilization of the most costly services, while at the same time achieving the desired patient outcomes inherent in the “Triple Aim”. To measure these elements of a successful clinical change on behalf of the patient, let’s move from the macro level of population health with its set of aggregated and manicured data to concrete clinical pathways of care. The focus must be on defining the detail-specific clinical treatment risks the provider is responsible for with patient engagement. We need to define the supports and clinical re-tooling needed to transition the paradigm from acute medical care to integrated collaborated care.
Moving population health goals from the national lens to the local community level and patient-specific need is essential in understanding the needs for patient engagement and the provider’s role in population health management and change. The development of an evidence practice center (EPC) in each care system is critical for mapping specific patient needs and risks; but, more importantly, it helps the provider understand where each patient fits into the landscape of risks and norms, as well as receptivity to a culturally relevant, evidence based practice. It is important to provide a communication platform for clinical and administrative guidance, and to maintain an exchange of timely information across care systems. Intelligently designed platforms are necessary to capture gaps in care, to flag risks before they escalate to acute care, and to accurately identify and measure the impact of defined clinical steps highlighted by the EPC. Protocols for engagement and treatment adherence are necessary tools to establish and ensure successful coordination across the delivery systems. Care coordination for a blended and collaborative treatment model requires the switch from an acute medical care paradigm to a true integrated care model that addresses the emotional, behavioral and social determinants that oftentimes play heavily in treatment adherence and risk.
To help the clinical workforce take on this challenge of a model change, one must address the culture of the agency and its commitment to change. Patient engagement and our own understanding of a patient’s motivation to engage in treatment is another key to meeting a patient’s needs. For example, does the clinical staff understand that motivation for change comes in stages, and that it is critical to help a patient understand that self-motivation is critical in helping the individual actively engage in his/her own treatment? Training on how to assess and implement Motivational Interviewing (MI) is only one of the steps in this process. It is just as critical to understand how and when to use MI in the treatment of the complex chronic care patient.
This brings us all back to the question: What is your own motivation for change? And, how are you using this concept and measuring it as a system or as a provider facing a substantial transition in the provision of care?