The Centers for Disease Control estimates 75 percent of all health care spending in the United States is spent to treat patients who suffer from chronic diseases such as heart disease, diabetes, respiratory disorders and arthritis. Many of these conditions can be managed, so that patients can avoid flare-ups, avoidable care at the Emergency Room or a preventable hospital stay and live healthier, active lives.
Iowa Health System has created Advanced Medical Teams at its hospitals, clinics and home health care affiliates throughout the region to help chronically ill patients achieve better outcomes. It launched the program early this year at Trinity Regional Health Center and Trimark Physicians Group here in Fort Dodge.
Each Advanced Medical Team is led by physicians who identify patients whose conditions can be better managed with one-on-one coaching, home health care, regular physician visits or community resources. Team members then develop a plan of care for each patient.
A medical care navigator works closely with patients who have chronic illness and are at risk to fail at home. The care navigator's focus is to help the chronically ill stay well, manage their medications and treatment plan the physician has recommended, meet their health care goals, and to coordinate care with their primary care physician and specialists. The services also include coaching patients to build confidence in managing their health to be successful. This may include changes that can be difficult to make, such as lifestyle or dietary changes. The services often include arranging for additional resources in the community such as nursing, Public Health, mental health services, Lifeline, Diabetes Center, Wound Center, Meals on Wheels, financial assistance, and transportation.
Trinity and Trimark's Advanced Medical Team began by focusing on patients who suffer from chronic obstructive pulmonary disease (COPD). Many COPD patients also suffer other chronic conditions, such as hypertension, heart disease or diabetes.
Care navigator coaches patients to manage conditions
Since the program started early this summer, our Advanced Medical Team has worked with more than 250 patients. Coordination of care may mean a referral to a community resource, or the care navigator stays in touch to monitor patient progress and follow-up appointments or therapy. One patient needed assistance to establish a primary care physician. She was seeing various specialty physicians but there was no one to see the whole picture of the patient. As her pain become more intense she was able to work with the family physician to get to the bottom of the problem. "Having a contact to call has been very helpful. I feel like I have another player on my team," the patient said in response to having a primary care physician.
Another patient had been in the hospital and the Emergency Room numerous times suffering from breathing and heart problems. In connecting the patient with nursing and therapy he was able to recognize early symptoms and receive help from his family physician or specialist who knows him and implement interventions before requiring a costly hospitalization or visit to the Emergency Room.
Helping avoid hospitalization
The AMT program allows us to identify these patients early, provide them the services they need and hopefully give them the help that will keep them well and out of the hospital. The program has helped Trinity achieve a 43 percent reduction in patient readmissions. Care navigators also are helping patients who may have used the Emergency Room as a physician office to be treated in less expensive, less acute care settings.
The Advanced Medical Team works together to assure that patients have the tools and resources they need to be successful. Patients know they can contact the care navigator, their primary care physician, or specialist to be proactive in addressing needs. Most patients want to maintain their health and reach their goals: we are here to help.
Dr. James Meyer is a pulmonologist affiliated with the Trimark Physicians Group. Janna Emick is an AMT care navigator at Trinity Regional Medical Center.