Longitudinal Support through Relationship
As we consider the application of population health management principles to value-based care, the fundamental differences between volume-based and value-based healthcare delivery are amplified. The third pillar of value-based care in this series focuses on longitudinal support and building better health care relationships with and between patients and providers. Value relies on members; volume relies on encounters. Value is relational, volume is transactional. Value is longitudinal, volume is episodic. (1)
Value recognizes that care teams must nurture their relationships with patients to understand and address their unique challenges, their goals, and their definitions of health and well-being. Engaging in such dialogue and relationship-building leads a person to feel valued as an individual, not simply as a widget in the production line.
As Atul Gwande said in his insightful book Better, “In (the) work against sickness, we begin not with genetic or cellular interactions, but with human ones.” (2) Therefore, human interaction is necessary to lead us to the wisdom of how to help one person navigate their personal challenges and, in the process, feel cared for.
Consequently, the pursuit of value yields a very different message to our patients. In volume, patients are numbers, whereas in value, they’re people. Volume is an episodic transaction, but value is a longitudinal relationship. Volume healthcare holds problem-oriented rescue as its theme, while in value, individually focused longitudinal support is our aim. My observation has been that people (patients, providers, and staff) know when they’re a number versus when they’re a person, and they respond to each designation predictably.
Value-Based Healthcare Delivery Consists of Better Coordinated Care
Lack of effective longitudinal patient support is highlighted in the efforts to decrease 30-day readmission rates to hospitals. I believe that most readmissions within a month of discharge occur because we, as providers and facilities, fail in either our quality or coordination in the delivery of care.
A failure in quality could refer to prescribing the wrong treatment or the wrong plan of care for that patient’s individual conditions and needs and highlights the need for risk stratification. A failure in coordination — the more common issue — represents a breakdown in the communication and management of the devised plan of care across the full healthcare continuum, leading to a lack of longitudinal support through all the transitions of the healthcare journey.
More importantly, regardless of governmental penalties for readmissions, patients are penalized more for a readmission than is a facility. Their health and well-being were not optimized (through support) to the point of keeping them out of the hospital shortly after already being there.
Communication and coordination are the lynchpins of longitudinal support. Without them, the model falls apart, leaving the patients in the gap to fend for themselves. Value-based Care is a team endeavor, and all the members of the Interdisciplinary Team (IDT) need to be executing the plan of care in a high touch, coordinated manner, appropriately applying the right blend of relationship and technology, reaching each individual’s specific and unique needs. The patient’s complexity, the local resource availability, and the regional expectations will all direct and drive the exact membership on the IDT.
The complexity of the plan of care determines how much longitudinal support is needed and who needs to be included on the team. Ideally, there would be one person or entity charged with coordinating the care delivery and communication between the patient, provider, and IDT as it executes the plan of care designed for that specific patient. This person on point for communication and coordination can be called a Longitudinal Care Advisor (LCA) – or manager, navigator, etc. Nomenclature is not nearly as important as function.
The physical therapist may need to let the pharmacist on the team know that the patient’s unsteadiness of gait seems to be related to the dosage or timing of their medication. The community health worker needs to know the plan for physician followup so that transportation and/or childcare can be arranged. The office nurse may need to refer the patient to a food bank and find out whether the patient followed through. This type of coordination and communication is nearly impossible without an electronic, up-to-date, editable, asynchronous form of communication that is accessible to the whole team.
Longitudinal Care Plans Must Focus on Patient Relationships
Don’t forget relationship, though. If a patient is simply shuffled electronically from one place to the next, even in a seamless fashion, the feeling of being cared for can be lost. In fact, patients can again be left to fend for themselves. “Feeling cared for” is subjective, varying from person to person, but without fostering that sense of relationship and caring, you greatly hamper the efficacy of prescriptive medical treatment.
That’s why patient experience is important — not just because of Governmental Star Ratings, or brand loyalty, or a willingness of patients to part with their money for a good care experience. Rather, positive patient experience has a profound effect on health and well-being. Helping someone feel cared for should be the primary goal in medicine.
Caring, not curing, needs to be our priority. Cures are great, of course, but life is always a terminal condition. However, to render medical treatment to a patient in such a way as to make them feel important, respected, and heard — to feel cared for — is a worthy and attainable goal. Organizing and communicating the plan of care and rendering the proper longitudinal support can be our most effective resource in this effort.
The upcoming final installment of this series will highlight a tool that assists in our ability to longitudinally support and adjust a high risk patient’s individual plan of care.
1 Don’t confuse episodic care with the “episodes of care” we see in CMS BPCI-A bundled payments. Value can be created through bundled episodes, like Total Joint Replacement, when the patient and their needs are considered longitudinally throughout the entire “episode.” This differs from episodic care where each encounter with the patient is a stand-alone process with no consideration for what has happened before or needs to happen after.
2 Atul Gawande, Better (New York: Picador, 2007), 82.
