Expanding Care Beyond the Physician

A patient who had recently been to see her primary care provider and was diagnosed with type 2 diabetes was surprised to receive a phone call from someone outside of the physician’s office. The person identified herself as a care manager and explained she would check in with the patient to make sure she was taking her new medication as directed and to provide information should the patient have any questions. The patient was experiencing a successful outreach from a member of her physician’s care coordination team. While this may come as a surprise to some, the care coordination model has actually been the “norm” at some level in most organizations for at least 15 years.

Why isn’t my physician calling me?

At its core, care coordination is based on better communication between all the providers involved with a patient's care. The “team” typically includes physicians, Advanced Practice Clinicians (APCs), social workers, nurse case managers, and pharmacists. They use data-driven tools and personal outreach to develop an action plan for each patient based on many factors that affect a patient’s health and ability to care for themselves.

“Expanding the care team has become more critical than ever before,” says Jonathan Burke, DO, CHCQM, Medical Director, Clinical Services with Populytics, a total well-being company focused on population health. “Physicians can’t do it alone and should not be expected to. We all know it takes a village to care for one patient, so a team-based approach is essential.”

Importantly, the care team helps physicians use their time more effectively and is the only way to meet the needs of an expanding patient population along with a shortage of physicians. In addition, a team provides the expertise and resources to customize care and provide support for people to better manage their own health. Simply stated – preventive care costs less for the patient and the health care system.

It's a matter of trust

The “physician-centric” mindset, where doctors are the only ones who can answer questions or provide insight, has gone by the wayside. With today’s technology and broader specialties, patients can access care and be accessible to their provider team outside of an office visit. More involvement in, and education about, care coordination is helping doctors and patients alike become comfortable with the expanded, more realistic approach to care.

Physicians understandably want to ensure that their high standards are being met. And patients do not want someone perceived as less trained to assume responsibility for their care, worrying that the change is driven by a desire to cut costs. That’s where trust becomes essential. It takes time and positive experiences to trust that care team members have the same focus and high standards as physicians do. Care teams are made up of licensed professionals who also learn from regular practice. They are typically highly skilled, have shared goals, have clear roles and responsibilities, learn to rely on and trust their team members, and communicate effectively.

“It's important for caregiving staff to get better at explaining to patients that they are utilizing different medical professionals to the full extent of their training and experience,” says Dr. Burke. “They need to assure patients that they will absolutely see a doctor when they need to. Providing care is indeed a team effort and the physician is always involved in decision making along with the other members of the team.”

Catching on to team health care

As more health systems and providers incorporate the care coordination/team approach, which does require a shift in thinking, the concept becomes more familiar and welcomed by patients. It’s helpful to remember that coordinating care among the team ultimately benefits both the physician and the patient.