Summer 2022

Industry Perspectives: Keys to Managing Chronic Disease Care and SDoH
By Sheila Magoon, MD
For The Record
Vol. 34 No. 3 P. 28

South Texas Physician Alliance (STPA), based in Harlingen, Texas, serves many patients who experience more challenges than the average American. The lower Rio Grande Valley has some of the nation’s highest poverty and unemployment rates, factors that have a huge influence on the region’s social determinants of health (SDoH). As a result, many of these patients lack the financial resources for medication, food, reliable transportation, and access to specialty care, which profoundly impacts their overall health outcomes.

About one-third of STPA’s patient population are people with diabetes, and approximately 12% have heart failure. As the STPA leadership team analyzed how to address barriers to patient care, it became abundantly clear that communication and coordination between health care entities (eg, primary care providers, specialists, and hospitals) was not optimal, especially for the patients impacted most by SDoH.

It wasn’t that “health care was broken,” but that the communication and coordination of care was inefficient. The medical issues STPA was trying to address had evolved past the traditional tools of communication—namely fax machines and phone calls—that were leveraged to address care coordination up to this point. Although some patients with more resources can make up the difference that an ineffective system creates, patients with compounding barriers of chronic disease and SDoH have difficulty filling the gap.

The physicians and leadership of STPA trained their sights on these barriers, partnered with a care coordination and communication technology partner, and set to work. One of their first pilot projects was implementing a heart disease management program—specifically heart failure—to keep the full care team on the same page and prevent rehospitalizations. According to preliminary data, the improved coordination has successfully reduced rehospitalizations of heart failure patients by approximately 25%. The program also improved STPA’s Medicare readmission quality measure.

When implementing this program, STPA identified three keys to chronic disease care coordination.

Patients With Chronic Disease Need a Wider Net of Support
Chronic disease and SDoH have a compounding effect on each other. That’s why looking at the patient holistically is so critical to improving health outcomes.

STPA found that a savvy care coordinator doesn’t just coordinate care between referring doctor’s offices, labs, image centers, and pharmacies. Instead, working to extend beyond the traditional health care players to include resources and support, such as social services, dietitians, and housing and food assistance programs, helps positively impact health outcomes.

Bringing these resources into the care coordination of patients with chronic disease helps address issues and barriers that underpin poor health. Now, health care providers, in concert with broader community resources, are not only elevating health on an individual level but also having an impact on overall population health in the lower Rio Grande area.

Seamless Processes Can Reduce Burdens and Burnouts
Prior to implementing care coordination and communication technology, there was significant unaccountability between referring provider offices. Disagreements over faxes never being sent (or properly received and acted on, depending on the perspective) were common.

Referral clerks were overwhelmed, but independent practices could not keep hiring additional administrative staff to manage the caseloads. As a result, not only was staff morale suffering but so was the timeliness of care. For example, mammograms would get pushed down on the priority list when the referral clerk had multiple cardiac patient referrals to schedule first. If the mammogram patient’s referral had to wait until the next day, so be it. If the patient was never scheduled for care, the responsibility often fell on the patient to follow up with both offices to get to the bottom of the issue—something that posed a significant challenge to patients already faced with chronic disease issues and other challenges to their health.

The process as it stood was untenable, so STPA began using technology that moved referrals, data sharing, and communications away from faxes and to a HIPAA-compliant, intuitive digital platform. After some experimentation with the technology, STPA improved the efficiency and effectiveness of communication between offices, which gave way to collaboration and support. Administrative staff were experiencing less burnout because they could easily send information, confirm its receipt, and schedule patients for timely care. The referral clerks could easily manage their existing caseload, and even take on more to free up personnel for other practice tasks. Most importantly, patients are less likely to fall through the cracks or need to repeatedly call their providers for appointments. These patients no longer shoulder the burden of coordinating their own care.

Everyone Needs to Be in the Loop
After a patient with chronic disease is released from the hospital, it’s their providers’ top priority to keep them from relapsing and being readmitted. This takes a significant group effort. The full care team, including care transition nurses, community paramedics, primary care providers, and specialists, need to be kept informed on the patient’s status and next steps.

For STPA, having a platform that allowed for the easy flow of information and follow-ups was a game-changer. For example, via the platform, the hospital discharge notice is shared with the full team so specialists and primary care doctors are able to schedule follow-up appointments. Members of the care team, who are accountable to each other, have access to health data from the hospital stay to address the patient’s care.

If a patient is readmitted, STPA has a clear window into where the system failure occurred. The hospital case manager and care transitions nurse can analyze whether there were any breakdowns in care coordination or whether the patient had a relapse due to disease progression that facilitated their rehospitalization. In either case, STPA can adjust and help the patient on a personalized basis.

Out With the Old
When it comes to chronic disease management for a population with significant SDoH, there is no easy answer. The status quo in most provider’s offices presents many challenges, most notably inefficient traditional methods of care coordination (primarily the fax machine). As a result, patients may slip through the cracks. These patients may never get the call-backs needed to close the referral loop and schedule their all-important follow-up care.

While chronic disease and SDoH haven’t evaporated since the implementation of STPA’s program, the organization has realized powerful results that push providers and administrative staff to continue to build out the number of providers and community-based organizations connected to the platform. By implementing technology that brings together an inclusive team of support for patients, communities can replicate STPA’s success and elevate health outcomes even for the most disadvantaged patients.

— Sheila Magoon, MD, is a family practice physician and executive director of South Texas Physician Alliance, a large independent physician association in southern Texas.