Tags: coordinated care , redesigning care

Dr. Nadaa Ali and Normie AllenDr. Nadaa Ali and patient Normie Allen

In the fall of 2012, Normie Allen of Roxbury wasn’t doing well. She was nearly 70 years old, and it seemed as though a combination of chronic ailments was going to overwhelm her.

First, there were her main conditions: diabetes and congestive heart failure. On top of that, she suffered from osteoarthritis in her knees. Combined with obesity, this was causing excruciating pain. She could barely walk, and often used a wheelchair.

Bill Theisen was getting concerned. Theisen is a nurse care manager who oversees Mrs. Allen’s treatment as part of the Integrated Care Management Program at Brigham and Women’s Hospital. He noticed that she was showing up frequently at the Brigham emergency room for pain in her knees and injuries from falls. Those visits didn’t help treat the underlying causes of symptoms and injuries – and they were adding untold costs to her care.

“Mrs. Allen was probably one of the most complicated patients in my panel,” said Dr. Nadaa Ali, a third-year resident who is Mrs. Allen’s primary care physician. “She was frequently seen in the emergency room and admitted to the hospital for pain control due to her severe osteoarthritis. Often, she would call me in pain that was caused from coughing from too much fluid accumulating in her lungs due to congestive heart failure.”

Dr. Ali got Mrs. Allen admitted for a stay at Spaulding Rehabilitation Center. With intensive physical therapy, Normie got stronger, and became less vulnerable to muscle pulls that would land her back in the ER.

“That was when she started to turn around,” said Dr. Ali, who sees patients at the Phyllis Jen Center, one of the physicians groups affiliated with Brigham and Women’s Hospital.

During a recent visit to Dr. Ali, Mrs. Allen met first with Bill, who asked Mrs. Allen about the medications she is taking – about 15 in all.

Then it was time to schedule procedures to help keep her healthy. He scheduled a mammogram for Mrs. Allen, and discussed a possible colonoscopy to check for colon cancer. He confirmed an upcoming visit with a nutritionist and scheduled a periodic visit with the orthopedist caring for Mrs. Allen’s knees. For the time being, she is getting by with periodic steroid injections and pain medication. Long-term, she may need knee replacement surgery.

There was a flurry of positive news: Mrs. Allen had lost eight pounds. She was taking only a minimal dose of oxycodone to manage the pain in her knees. And she had discontinued using her CPAP machine, a breathing assist device she had worn during the night to control sleep apnea.

Dr. Ali continued the examination. She was concerned about Mrs. Allen’s hemoglobin A1c level, a measure of the average blood sugar in a diabetic patient’s blood as measured by a lab test.

“I think we should set a goal that within the next six months we get your diabetes under control,” said Dr. Ali. “Our pharmacist can help us with that. I am going to ask her to follow you more closely.”

The Integrated Care Management Program (iCMP) is just one piece of Partners HealthCare’s larger Population Health Management (PHM) initiative. Under PHM, doctors track the health of the entire population of patients they care for, not just the ones who show up for appointments because they feel sick. Overall, the approach helps keep patients healthier, and lowers the cost of care by, for instance, preventing unnecessary hospitalizations.

The iCMP program is a way of focusing attention on the most medically complex patients to coordinate their care and better manage chronic conditions. Patients often become more involved in their own care and change unhealthy behaviors. That helps reduce unscheduled visits to the ER, which are costly and do not always provide the best care for chronic conditions.

“When I first met Mrs. Allen,” recalled Dr. Ali, “she couldn’t lift her foot high enough to get up the stairs. She was in a wheelchair, and that kept her from making her doctors’ appointments. Today, she comes to her appointments with a cane. This is a big improvement.”

Bill Theisen, the nurse care manager, had one more question for Normie. “You seem to be doing much better this year,” he said. “Why do you think that is?”

Mrs. Allen didn’t hesitate.

“It’s because of all the nurses and doctors taking good care of me,” she said.

Hear how another patient’s experience with population health management has helped improve his health outcomes.