Results are shared daily among the staff and leadership to quickly identify opportunities for improvement. "We focus on whether the engagement with the patient has been successful," she says.
Using real-time clinical data, the team can see if engaging a patient and building a relationship helped improve A1C levels, renal function, and eye health—deterioration in any of these areas could cause a patient to be labeled high risk and to receive higher attention.
Appel says one way to justify the cost of case managers is to map that cost against known disease progression costs—such as the cost of care for strokes, blindness, and limb loss—over the lifetime of the patient.
Using technology, including texting and automated vital sign collection, Sharp Rees-Stealy has been able to increase nursing panels. Patients use at-home monitors to transmit their vital signs for asthma, COPD, hypertension, and other chronic conditions directly into a centralized application.
If data is missing, staff at Sharp Rees-Stealy Medical Centers are alerted via a dashboard and can contact the patient to troubleshoot issues such as a disconnected device.
Also, rather than calling patients and waiting for them to call back, care coordinators can use texting to conveniently connect with them and share information.
Technology has helped the organization reach its goal to engage 5% of the population—or nearly 10,000 patients—through care coordination. "That would be hard to do without
creative resources," Appel says.