Improving Chronic Disease Care— A Snapshot of What’s Working in Health Centers

Ellen Robinson, MHS, PMP, is the Director, Information Resources and Outreach, in NACHC’s Clinical Affairs Division.

In providing chronic disease care management to health center patients, care teams are doing so with an understanding and sensitivity that many patients face one or more environmental and/or educational barriers. Reducing heart disease takes an all-hands-on deck approach.

Multidisciplinary approach is key

“Truly, we have a whole team approach,” says Cynthia L. Jones, MD, Chief Medical Officer, Mosaic Health. “From the scheduler to the lab schedulers and techs, nursing staff, social workers, insurance managers, pharmacy staff, and providers – everyone is involved… The days of working in a silo as a physician are over.”

At Zufall Health Center, Rina Ramirez, MD, Chief Medical Officer, shares that as part of their multidisciplinary approach, clinical pharmacists (rather than primary care providers) provide patients with more in-depth diabetes education and medication management through several consultation sessions. In addition, needs assessments by different care team members are performed to ensure barriers that may impact a patient’s care are captured. Care team members then collaborate and coordinate care and services such as nutritional counseling, low cost or free healthier foods, low-cost medications or laboratory services, medication education, behavioral health counseling, etc.

Educating patients through ongoing engagement

Ongoing high-touch engagements with patients about their chronic conditions is also a core part of many chronic disease management programs. “The single best thing we can do is educate and motivate our patients,” advises Keith Ferdinand, MD, Gerald S. Berenson Endowed Chair in Preventive Cardiology, Professor of Medicine, Tulane School of Medicine. Information should be simple and clear (e.g. simple low-lit infographics) and culturally appropriate. For older adults, Ferdinand recommends using caution when directing these patients to websites because they may not use the Internet to search up health information and if they do, they tend to find a lot of misinformation.

“We take our time to educate high-risk patients through phone calls and in person and we give them a lot of time to ask questions,” says RN Managers Christine Lynch, RN, and Rebecca Horning, RN, Mosaic Health. “We’re constantly myth busting or helping patients get past a bad experience (when using statins). We spend a lot of time on the ‘why’ and ask ‘what’s preventing you from taking your statins?’” Once the care team knows the “why” they can get patients resources that help solve a specific problem.

Chronic disease strategies at-a-glance

  • Run Gap reports in EHR systems to identify patients who need treatment intensification, follow-up, lab work, or needs assessments to address barriers and/or gaps in care.  
  • Feedback from both staff and patients is key to enhancing and improving patient care.  
  • Incorporate high-touch education touchpoints during the visit with “teach back” opportunities and two-way conversations that meet patients where they are.  
  • Avoid overwhelming patients with too much information that is difficult to understand. Use motivational interviewing to hone in on one goal or action they can work toward.
  • Conduct frequent follow-up phone calls and/or virtual video calls to help keep patients engaged and on track with their medication regimen and/or behavioral lifestyle changes. 
  • Educate teams, from front to back office so everyone understands the health center’s efforts to reduce blood pressure, cholesterol, A1C, etc. among patients with chronic conditions and can support a to chronic disease care.

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