Why we need team-based chronic care management

Categories: Capacity Building

A few years ago I was involved in the case of John Smith (not his real name), a patient who was referred by the hospital emergency department (ED) to a care management team in a low-income urban community in New Jersey. John was a homeless man who’d been living in an emergency shelter for three years with insulin-dependent diabetes, blindness, and chronically low sodium levels. The team consisted of a nurse case manager, a social worker, and two community health workers.

team-based careBecause of John’s multiple disorders, his management was complicated and he fell into a cycle of bouncing between the ED and his assisted living facility. During one particularly difficult weekend, John was brought to the ED three times. Only after the nurse case manager and I spoke to his treating physicians at the hospital and nursing home were we able to determine the cause of all his ailments. They placed him on appropriate medication.

The care management team continued to work with him, arranging an appointment with an ophthalmologist who determined that his blindness was due to cataracts, which were corrected with surgery. With his vision restored and his medical conditions managed, John was able to find stable housing, was linked to primary care, and is currently living independently.

He had no further ED visits.

This is an extraordinary case where the application of team-based chronic care management (CCM) was able not just to help a patient get healthy, but to take control of his life again. This is not an isolated incident; countless others have had their lives restored by using a team-based approach to look critically at the source of a patient’s ailments, instead of seeing only the symptoms.

To help other health centers make a difference for their patients, the Primary Care Development Corporation (PCDC) recently released a report entitled, “Delivering Team-Based Chronic Care Management: Overcoming the Barriers.” It provides recommendations to support better health care, particularly for high-risk, high-need individuals, and was based on ground-level work led by PCDC with five New York State Health Homes.

PCDC believes that primary care is the foundation of health care delivery. By investing in the right tools, such as proper care management and a patient-centered approach to care, it can achieve the quadruple aim and improve the quality of life for all patients, especially the most vulnerable like John.

About the Author

Ruth Perry, MD, Chief Program Officer

Phone: 212-437-3921Email: rperry@pcdc.org Ruth joined PCDC in 2016, bringing over 25 years of experience in clinical practice, management, social entrepreneurship and health care transformation. As Chief Program Officer, Ruth is a member of the Executive Team and is responsible for setting the strategic direction of the PI group, leading new program development, providing existing program oversight, and supporting the work of the Capital Investment and Advocacy groups. Prior to her role at PCDC, Ruth served as the Executive Director for the Trenton Health Team, a community-based health improvement organization and a Medicaid Accountable Care Organization. In addition, she has served as a featured speaker and panelist locally and nationally, and has served on several arts nonprofit boards. Ruth has a BA in Biology from Swarthmore College, an MD from Temple University School of Medicine, and is a Board certified Internist.