COMMUNITY VOICES: A Q&A from U Chicago Medicine,
In this series, the University of ChicagoMedicine examines health-related challenges faced by communities served by the South Side-based academic health system through interviews featuring a variety of perspectives. This is the third in a 10-part series.
Interview: Dr. DorianeMiller and Dr. Rajlakshmi Krishnamurthy talk about how better coordination of care results in improved health outcomes. Q: What is coordination of care and how can it contribute to health equity?
Miller: Care coordination is important because most health care takes place outside of a physician’s office. As a primary care doctor for adults, I take care of a lot of patients with diabetes, and the information that I share with them about good self-care includes whether they can get healthy foods in their neighborhoods and have opportunities for exercise and physical activity. And not just opportunities, but whether it’s safe to do so, whether they can afford the medications that I’m prescribing, whether they can get to appointments if there are transportation challenges.
Figuring out how to deliver high-quality care goes beyond what I do as a primary care provider, and incorporates a team of people who work with me. I work with nurses, social workers and medical assistants, and they have a team of people who work with them to help provide well-coordinated care for my patients. Krishnamurthy: In addition, many of our patients who have multiple medical problems might see a primary care physician, a cardiologist, an oncologist or surgical specialist like a urologist. And they might see those doctors at different institutions— at their health center, at an academic medical center or a hospital. The nurse care coordinators and community health workers that we deploy sift through all the information, including patients’ medications. With patients’ permission, these workers may even open refrigerators to check availability of food.
Miller: People sometimes think of caregivers in a formal capacity, people with a degree after their names — doctors, nurses, people working at home health care agencies. But family members and friends are a very important source of caregiving, and oftentimes serve as unpaid care coordinators for their loved ones. The ability to help these caregivers navigate all of the different systems is very, very important. And the patient shouldn’t have to be carrying information from system to system to system. There needs to be easy access to it. In this day and age, that usually is the electronic health record.
Q: How do you use electronic health records?
Krishnamurthy: With our electronic records, we’re now able to create registries and algorithms to identify who’s been in and out of the hospital and who needs to be screened for behavioral health, for example. We’re able to look at groups of patients that we take care of and target interventions, or opportunities for screenings, in a more informed way. A big component of what we do is using the electronic medical record to identify people who might have slipped through the cracks.
During COVID, we’ve had quite a few patients with diabetes and hypertension who haven’t come back for care. Now we’re using those registries to reach out proactively. We’re not waiting for them to come to us with a stroke or an infected leg. The electronic record and some of our ways of thinking about our patients from a population health perspective have helped us do better in terms of our care delivery.
That’s the real inspiring part for Dr. Miller and myself being involved in this work. It’s really about getting to the root cause and trying to preserve population health, rather than always dealing with the consequences of disease.
Q: Does that mean it’s easier now to coordinate care? Krishnamurthy: Many of the academic medical centers in Chicagoland are on the same system, and there’s the ability to see information from different systems. But not all. If you’re in the VA, if you’re in an FQHC (Federally Qualified Health Center), you may not be on the same system. We may not be able to see your X-ray or your CAT scan or your lab tests. And those are all critical pieces in helping us decide treatment.
Miller: In the face of COVID, we’re doing more medical visits via smartphones or computers, and I can actually do a virtual house call. I can see patients in their home environment, oftentimes with their caregivers in the background. I can see how they’ve got their medication set up. If that person is on oxygen, I can see whether they’re using it. I can also see if they’re living in, say, a split level home, if they have a bed set up in the living room where people are moving back and forth. Knowing those kinds of things gives me additional information and are a reminder of why it’s so important to have home health agencies involved and other people there to support the patient.
Q: In terms of racial disparities, I would think that the more vulnerable you are, the more important it is that your care be well-coordinated.
Krishnamurthy: At the University of ChicagoMedicine, our programs for high-risk care coordination identify patients who are multiple-visit patients— who are hospitalized a lot or come to the ER frequently. Oftentimes there’s a trigger in the environment that affects their health and their outcomes. We use our high-risk care coordinators — RNs, social workers, community health workers— to connect with those patients because the relationship aspect of care is an important driver of continuing to follow through.
Early in the COVID pandemic, we were proactively reaching out to some of our older patients who lived in vulnerable ZIP codes that the mayor’s Racial Equity Rapid Response Team had identified. They couldn’t get access to food because they couldn’t afford the $5 or $10 disposable masks. We sent out masks that were washable so they could go to the grocery store. It’s things like this, just understanding the context in which they’re trying to take care of themselves, and helping to support them so they can take care of themselves.
Miller: Oftentimes it’s asking “the question behind the question” about what patients are struggling with, rather than assuming that they don’t want to be engaged in their own health care. Pre-COVID, I gave a prescription to a patient and asked her to go to her local Chicago Park District facility to exercise, which was about three blocks from where she lived. She has high blood pressure, diabetes and obesity. I thought this would be a great way to address all of these problems. I sent her away with a prescription that would allow her to participate in park district services for free. But when she came back to see me, her blood pressure, weight and blood sugars were unchanged. She shared with me that because of safety reasons in her community, specifically some gang-related issues, that she was unsafe walking to the park district facility. It is important to have candid conversations with your patients and then to problem solve and share decision making around what will work for them. They want to take care of their health; otherwise they wouldn’t be coming in to see us, and we want to do our best to support them.
Q: It sounds like it requires more work and more health providers. I suppose that work is on the front end rather than down the road?
Miller: If you remember the phrase, “Many hands make light work,” it really does involve teamwork. The delivery of care is a coordinated effort. If I were sitting here as a primary care provider and thought that I could do all of those things on my own, it would be a monumental task, near to impossible. I’ve worked not only in an academic setting, but have spent most of my career in safety net settings. And I’ve sometimes thought that if I had been trained as a social worker, I probably would have been more effective as a physician in helping my patients get the services that they need and figuring out how to coordinate it. But we have people who can pick up the ball where we leave off and figure out ways to provide these services for patients.
Q: When care coordination doesn’t happen the way it should, what are the obstacles?
Miller: There’s the issue of cultural competence. As I think about the patients that we care for, primarily on the South Side of Chicago, and having majority-minority racial and ethnic communities, our community health workers understand the circumstances that patients live in because, oftentimes, they come from the same communities and the same backgrounds. Having that firsthand knowledge of the challenges and struggles within these communities, as well as about community resources, makes a difference in helping to fill in gaps as we think about ways in which we can narrow health disparities through enhanced care coordination.
Krishnamurthy: In the past, care coordination was largely done by insurance companies. In recent years, with more value-based care initiatives where health systems work with the insurance companies— whether government, Medicare, Medicaid or private companies like Blue Cross— we’ve worked more in partnership to manage costs. That has given us, as the providers of health care, an incentive to hire our own care managers. We can target the folks that we think would benefit from this help and build clinical programs to help support that. It’s not something that’s paid for separately, by and large. If we are in shared contracts with payers, we’re able to carve out some dollars. Funding things like community health workers and care coordinators is a challenge. But there’s been some movement to try to do this. There’s a lot of work around community health workers and expanding their scope. But there’s still a lot to be figured out about how we pay for these things.
Q: Can you share a patient story that illustrates how care coordination can positively impact health outcomes?
Krishnamurthy: A gentleman followed at UChicago Medicine IngallsMemorial was living in his car. Because he didn’t have a permanent address, he was coming through the ER to get routine dialysis for his end-stage kidney disease. His care manager helped him fill out a Medicaid application, get into a long-term dialysis center and apply for permanent housing.
Miller: Another patient called her doctor during the shutdown. She’s blind and has diabetes, and ran out of food and did not have a way to get more. Through our social worker we arranged for a contactless delivery from the Greater Chicago Food Depository. Our social worker went above and beyond by going out and buying the first meal and delivering it herself.
These are both tremendous success stories that demonstrate how we now have to think about delivering health care.