Traditionally, the American medical community has focused most of its efforts on treating patients who are ill or in need of lifesaving treatment.
"In general, we don’t have a health care system in our country; we have a sick care system that responds when a heart attack patient shows up in the hospital room," says Dr. Lee Mills, St. John Clinic medical director. "We do a great job once something bad has happened. We have heroic intervention; we don’t have a wellness or health system."
Preventive or wellness care is not a new concept, but it is not widespread. Nationally, Americans only use preventative services at half the recommended rate, according to the Centers for Disease Control.
The St. John Health System’s Care Management Program is on a journey to replace this longstanding, reactive approach with a proactive, team-based one that turns patients into partners with their physicians.
At St. John, instead of seeing one doctor, patients are cared for by a team of professionals with interlocking, mutually supporting expertise to keep the population healthy and improve wellness. Equally important, whether a patient is in the hospital, at a St. John urgent care clinic or at a physician’s office, their medical information is current and consistent.
Comprised of physicians, nurses and other related personnel (see box), these teams manage the flow of information across the health system, Mills says, and they "are even expanding to include behavioral therapists and pharmacists, with aspirations to expand into health coaching to help patients walk through difficult behavior change."
The first nurse care manager was hired in 2013, and there are now 40 nurse care managers across the St. John system (see box).
Also, "We are paying attention to what patients need all the time instead of just when they call," says Pamela Copper, St. John Clinic director of operations.
Electronic health records and the care manager dashboard identify patients who have been in the hospital or ER, and nurse care managers check in to make sure they have filled medications and have follow-up appointments with physicians. They also can arrange for other services such as home health, Meals on Wheels or oxygen delivery, she says.
"If they are diagnosed with something new, the nurse can provide education about that to make sure they have what they need to stay home and be healthy and not be readmitted to the hospital," Copper says.
Although their jobs are not medical in nature, informatics professionals particularly play a key role in delivering proactive care by building tools to retrieve patient data and provide insight into their needs. Copper says informatics professionals help move data to information and information to wisdom.
Patients and their care remain top priority with the program. Some physicians make rounds daily; others do not. Through the Care Management approach, patients are seen by a team member such as a nurse or physician assistant each day.
"In the old model, there are not enough primary care physicians guarding the gate to take care of every patient," Copper says. "The team approach is data driven."
Data gives teams insight into the patient population, including disease prevalence. Care plans can be developed, as can programs for population cohorts to better address patient needs. The team can see if patients have undergone recommended health screenings and address future health needs, she says. "Moving to teams keeps each person working at the height of their expertise, working together."
With a team of professionals, care is available to more patients overall, helping physicians care more fully for their patients.
The new approach is being implemented across all of St. John’s Clinics and is available to any patient regardless of age or economic status. The St. John Health System Foundation is one avenue that helps to expand existing services and add important new programs, such as Care Management.
Elizabeth Haller is one patient who experienced the benefits of the Care Management Program early on. At 33 and in seemingly good health, she suffered a stroke on Jan. 22, 2015, that left her unable to talk or move.
"The Care Management Program not only keeps the care team communicating, but most importantly, it benefits the patient by keeping them on track with their treatment plan," Haller says. "Every single doctor that I saw knew my history. All the nurses that cared for me at St. John Clinic knew my history. From primary care, to the Coumadin clinic (medication monitoring) and the outpatient stroke clinic, they had full knowledge of my treatment and recovery plan."
The process was flawless, she says. "Everyone is on the same page, and I truly felt and still feel like everyone actually cares how I am doing at three years (post-stroke) with a full recovery."
As opposed to a set-in-stone program, Care Management is ever-evolving.
"We are constantly evaluating what our patients need, how to deliver that before disease or illness begins, and deploying that in our clinics," Mills says. "It’s obviously a process; we are three or four steps forward into a long journey. We are continually refining the program and improving to be sure we are effective stewards of our resources — to get the right care to the right people at the right time."