The Sauce vs. Soufflé Approach to Care Management: Implications for Health Reform

Thanks to all those cooking shows, the Disease Management Care Blog fancies kitchen metaphors. In thinking more about yesterday’s post on ‘care management,’ one allegory came to mind: the making of sauces versus soufflés. It occurred to the DMCB that care management, despite all the scientific trappings, is best thought of as a sauce. How well health reform can swallow that remains to be seen.

When the DMCB makes spaghetti sauce, it knows the red stuff basically involves tomatoes. Once that basic ingredient is fulfilled, the rest is a creative mix of spices, maybe some wine, chopped sweet peppers, mushrooms, onions, garlic, other stuff and what-the-heck whatever-this-is-from-the-fridge and then drinking some wine. Think The Godfather’s Peter Clemenza and his famous going to the mattresses recipe for 20 guys.

Then there are soufflés. The closest the DMCB ever got to that level of culinary expertise was when it tried to make crème brûlée. What unfolded early the next morning wasn’t pretty. The point is that the DMCB appreciates that soufflés require an extraordinary level of cookery. The ingredients have to be apportioned in exact amounts, their mixing has to be precise and the oven temperature and bake time must be unerring or the result will be a stone. In medicine, think the operating suite and making sure the same check list is completed all the time every time.

When guests sit down to the DMCB’s sauce n’ pasta, they know what it is and it usually does the job. In the world of case management, the red stuff (otherwise known as the key core ingredient) is the generalist registered nurses referred to in Dr. Bodenheimer’s New England Journal article on care management. The rest is based on nursing science, lots of opinion, local culture, available resources and what’s in the fridge.

Check out the peer-reviewed literature used by Dr. Bodenheimer to make the case for care management. There is one reference on advance practice nurses and the role they play in helping patients discharged from six city hospitals, another on ‘trained nurses’ using a Care Transitions protocol for recently discharged patients in Colorado and primary care-based registered nurses in Baltimore who had completed a course in ‘Guided Care Nursing .’ There are other examples used in the article, including a geriatrician-led high risk clinic doing home visits, a roving geriatric physician-two nurse team managing 300 patients and the CMS capitated benefit plan called PACE. All are unique, yet all share the key ingredient of nurses doing nursing stuff that help patients move from point A to point B. It’s what does the job.

In the DMCB’s recent American Journal of Managed Care editorial, it argued that population-based programs for the care of patients with chronic illness are necessarily varied. The core ingredient makes it recognizable but around it there is considerable creativity and flexibility. Dr. Bodenheimer’s article didn’t necessary address the non-uniformity of care management, but the references he used certainly speak to that dimension.

As a result, it will be very challenging for accreditation agencies, recognition programs, managed care and accountable care organizations as well as Federal health reform and all the necessary regulations that follow to accommodate all those excellent cooks and their wonderful savory creations in the delivery of care management. Hopefully, the powers-that-be will recognize the need for flexibility in this area.

Hopefully, they'll be less about soufflés and more about sauces.

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Post script: The closest Dr. Bodenheimer has come to endorsing disease management is also in this New England Journal article:

'Telephonic care management has been effective when combined with face-to-face visits but has not worked by itself.'

Welcome to the club, Dr. B. The DMAA's been pointing this out for over a year and regular readers of the DMCB have long been familiar with the concept.