We hear so much talk about (and many of you are already working with) coordinated care teams for patients with diabetes, which may include nurses, pharmacists, dietitians, certified diabetes educators, and health coaches. But how many patients are actually experiencing such team care?
A John Hartford Foundation study found that a paltry 27% of older Medicare-eligible patients said they received coordinated care when provided with various descriptions from which to choose. Strikingly, within this group, 83% reported feeling that this type of care led to improved health. Of individuals who were not part of such coordinated care teams, 73% said they would like to be.1
Medicine has at times been slow to embrace technology to enhance communication. That we only recently began widely using electronic health records (EHRs), and still send faxes, lends evidence. Diabetes care, to take just one example, is complex and can be daunting—for both patients and health care professionals. How can we leverage resources we already have at our disposal, further tweak them as needed, and use them to help everyone better engage?
1. Take the wide-angle view—use big data
Big data can expand our perspective and remind us that clinical care is but a small slice of the health outcomes pie. It’s estimated that only 20% of a community’s health outcomes depend on the interactions that absorb our workdays.2 Patients must address challenges that may hinder even the most carefully assembled treatment plans—financial barriers, time pressures, the inertia of the familiar. Keeping this larger perspective in mind will help both patients and us, so we can proactively anticipate potential obstacles, and implement solutions.
What are some of the factors that comprise the remaining 80%? Health behaviors, such as diet, smoking, and alcohol use; and broader measures, including education, socioeconomic status, air quality, housing, and income, can affect a patient’s ability to implement changes that we discuss and recommend. The CDC defines these social determinants of health as “the complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities.”3
Beyond data from EHRs, information on how far individuals live from a market or pharmacy, or regional data on potential environmental hazards, are important. What do we do with all of this information? We can analyze what we collect to help assess health literacy, as well as tailor screenings and interventions.
2. Use technology at the individual level
I’ve long been by turns fascinated, puzzled, and at times frustrated that virtually all of us have powerful devices that we can fit in our hand and carry around everywhere—a smartphone or a tablet—but we aren’t better at harnessing these in the service of a single mission: to coordinate diabetes care. We can use these technological tools to promote enhanced communication between patients and their health care team. Not only that, we can also use them to optimize coordination among members of the health care team. One of the crucial, evolving challenges is ensuring information shared by apps is based on sound clinical evidence, as many apps are not vetted and may provide inaccurate information.
How can we leverage apps to help ease patients’ recording of self-monitored blood glucose measurements? (These also help circumvent forgetting to bring that old-fashioned paper log book, since patients generally don’t forget their phones!) What about websites that provide patient- and caregiver-friendly information to arm them with knowledge and strategies? Or sites that allow patients to communicate with each other?
3. Tools enhance, but don’t replace
We must always remember that any tool, no matter the number of advanced features it boasts or how “cool” it is, doesn’t replace interacting with people. Patients—and, I would argue, health care professionals—need to check in regularly to encourage, advise, address questions, and troubleshoot. All members of a diabetes care team can contribute. Health coaches can also play a crucial role between visits, by helping patients navigate an unending and, at times, winding road.
With increasing efforts to incorporate electronic tools, whether for a population or for a single person, we must continue to be mindful of and honor that patient who is sitting across from us in the exam room. Even in the face of multiple obstacles—time pressures, a seemingly limitless number of boxes to check off in the EHR—every patient has a story. Let us balance cutting-edge innovation with equally high-level compassion, humility, and humanity.
1. Phillips Q. Uncoordinated care. Diabetes Self-Management. April 23, 2014. Accessed December 3, 2017.
2. University of Wisconsin Population Health Institute. County Health Rankings and Road Maps, 2016.
3. CDC. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. NCHHSTP Social Determinants of Health, Definitions. Last updated March 14, 2014. Accessed December 13, 2017.
Another helpful article
Handmaker K. Incorporating social determinants into population health. Healthcare Financial Management Association. March 2017. Accessed December 10, 2017.