Sunday, February 27, 2011

All Health Care Is Local. So Are Truly Successful Care Management Programs

If you had to make a wager on care management, would you put your money on local talent and hard work, or blaming inertia and budget shortfalls? Well, thanks to two presentations at the recent Health Canada conference it participated in, the Disease Management Care Blog's betting on the talent and work.

The first was by a physician at a regional hospital that scraped together small amounts of internal and external funding for three interrelated initiatives: 1) hiring a diabetes case management nurse who was shared by 35 primary care clinics, 2) alerting all physicians with "pink sheet" notifications about patient A1cs that are out of range and 3) creating a "standard inpatient order sheet" (an example from another institution is here) designed to combat sliding scale insulin and promote the use of basal insulin. All three led to statistically and clinically significant improvements in blood glucose control.

The second was by a registered dietitian who described how a group health center developed blanket medical "directives" (not to be confused with end-of-life "advance directives") that allowed non-physician professionals to semi-autonomously initiate changes in patients' diabetes care plans while they were interacting with patients via telephone, individually and group visits. Compared to a quasi-experimental control group, multiple measures of diabetes quality (cleverly combined into what was termed a Good Health Outcomes in Diabetes or GHOD score) showed statistically and clinically significant improvements over several years.

Both presentations demonstrated how great programs often have to start with small beginnings, usually involving nimble and dedicated visionaries who understand that good ideas and a successful track record can create its own funding streams, not vice versa. And speaking of a track record, both programs would not have gotten as far as they did without committing considerable resources to recording and analyzing their data on a prospective basis.

Want to start a a) medical home, b) disease management program, c) inpatient work flow solution or d) decision support system but blame the "administration," lack of "funding," colleagues' inertia and other resource constraints? Think you need "support" from the central government, or that you "deserve" square feet and full-time-equivalents and no one will cough it up? It may all be true, says the DMCB, but it was also true for the two presenters above, and they didn't let any of that get in their way. They boot-strapped their way up and were careful to document outcomes along the way. They just "did it."

Last but not least, the DMCB points out that the programs above were far away from the spotlight of academic approbation, policymaker awareness or government support. That is, literally far away, as in the heartland, hundreds if not thousands of miles away. In its travels, the DMCB has found the same has been true in the United States, such as Portland Maine, West Allis Wisconsin, Albany New York, and Boulder Colorado. As we continue to look for good ideas to achieve the triple aim, the Health Canada Conference served as a useful reminder that maybe all we really need to do is look no further than in our own backyards.

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