Holding Hands

As providers have begun to shift away from focusing purely on clinical outcomes to take a more holistic, patient-centered approach of looking at a patient’s overall quality of life and well-being, the role of the nurse care manager has been gaining significance.

In the past few weeks, I’ve been speaking with care managers to better understand their role in the current care workflow. In my conversations, I found that there are three key ways that care managers improve the overall health of their patients:

1. Patient engagement

The key to providing better overall care is to approach patients in a way that gives them encouragement, empowerment and support. One care manager mentioned that she set small achievable goals with the patient and spoke with patients in a way that encourages them to be proud of their small steps. This allows the patients to gain overall confidence in themselves and take ownership of their own health. In one example, a patient not only started to self-track her own health, but also proactively called the care manager on how to improve. With the patient being engaged in her own health, by the next clinic visit the patient was even able to see slightly improved health outcomes (improved HbA1c levels).

2. Early detection of issues

Care management helps increase the number of touch points with patients. Those touch points allow the care manager to gain a more complete picture of the patient’s progress at home, detect urgent issues earlier, and follow up with any extra support as needed. For example, a care manager described to me a scenario she experienced with an elderly woman who had been discharged. From the EMR clinical notes from the woman’s previous visit, it was hard to tell how the patient was progressing. The care manager called the patient and was able to speak with the patient’s daughter, only to realize that the patient had critical temperature levels and symptoms that called for an urgent visit with her PCP. With early detection of a developing issue, this was one hospital visit avoided.

3. Filling the gaps in care

It has been shown that care provided for patients in transitioning from hospital to home can prevent the most readmissions. Care managers serve the role of being an accessible resource and support system for the patient upon discharge from hospital and in between clinic visits. One of the primary tasks care managers take on involves triaging patients since many of the patient’s issues at home aren’t clinically related and do not require a physician’s expertise. For example, one care manager mentioned that a patient had been missing his upcoming appointments simply because he didn’t have transportation to get to the appointments.

As provider organizations work to integrate care management into their practices, there will be struggles to streamline care workflows; however, even in these early stages, we can see that there is much value to the work of care managers in providing patient-centered care for individual patients and in improving overall population health as well. This growing role of the care manager now calls for tools that can help them more efficiently perform their important work.