A new partnership between Monticello Medical Clinic and Drew Memorial Hospital aims to improve health outcomes and reduce readmissions to the hospital.
The family practice physicians recently began referring patients with chronic conditions to the hospital’s new Chronic Care Management program, led by Monticello native Jonathan Schell, RN, BSN, ACM.
With health care costs rising, Medicare decided to take a proactive approach to keep Medicare recipients out of the hospital. Thus, Chronic Care programs were born. It’s a service provided by Medicare and the proactive family physicians, and in Monticello, the hospital also has a big role.
It’s part of the reason Schell was interested in the position. “This is one of those instances when it’s so nice to see hospitals, physician practices, and insurance companies all working together toward what’s right for patients,” Schell said.
Chronic Care Management, housed at DMH, currently includes a staff of four chronic care coordinators, supervised by Schell, who reach out to patients on a monthly basis to discuss their medical needs. Eligible participants are patients of a Monticello Medical Clinic physician who have been diagnosed with two or more chronic conditions. Chronic conditions are any diagnosis that is considered long-term. When patients have more than one chronic illness, their health can become difficult to manage, which sometimes leads to exacerbated conditions or new chronic illness.
The monthly calls from CCM staff are designed to check in with the patient on the management of their conditions, ensuring the conditions do not become critical enough to require hospitalization or an ER visit.
“This national push for chronic care management focuses on Medicare patients with two or more chronic care needs because that population uses a majority of Medicare funding,” Schell said. “This is basically a step toward preventive care – keeping people healthy, and avoiding more complicated illness.”
Patient participants are monitored through a combination of regular doctor’s visits and phone calls. Their MMC physician ultimately guides their care plan, but CCM staff can help keep the patient on track between visits, even helping patients to avoid unnecessary clinic visits. A patient can call the CCM line directly to get results during business hours without having to leave the comfort of home. After hours, MMC’s call center will answer CCM patient calls. The overall goal is to reduce readmissions to the hospital, and, Schell said he sees CCM being especially effective in preventing borderline admissions, admissions to the hospital that may not be necessary.
“There are a variety of conditions we’ll be monitoring, so we could be talking with a patient about the diet their physician recommended or a medication regimen.” Schell said. “We will check on how new medications seem to be working, make sure they don’t have any reactions, ask if the patient needs a prescription refill called in or if the patient needs transportation assistance in getting that prescription picked up.” When a refill is needed, care coordinators can work with MMC to call in a refill, or will set up a face-to-face appointment with the physician if appropriate. When it’s not necessary to meet with a physician, the phone conversations will save the patient a trip and wait time. Alternatively, if a conversation identifies an urgent medical need, coordinators are able to escalate calls to the physicians.
Schell expects this will lead not only to healthier patients, but also increased patient satisfaction.
“This is a forward-thinking operation,” he said. “We’re saving them some travel time when appointments aren’t necessary, and we’re checking in often. I think this will be a very positive patient experience.”
Schell is a key player in implementing the program from scratch. While the family practice physicians are closely involved, Schell will handle most of the program’s micromanagement, freeing the doctors to spend more time with other patients. He hopes to expand his CCM staff as the patient base increases. Since implementation in early June, more than 300 MMC patients have been enrolled. Schell hopes the program will serve 3,000 patients within the first year and looks forward to expanding the partnership in the area.
Beyond his enthusiasm for developing the Chronic Care Management program, Schell is excited to be back home. The Monticello High School and University of Arkansas at Monticello graduate has close family in town and his wife Katherine is from nearby Monroe, Louisiana. “I had a wonderful experience growing up in Monticello, and now that I’m back, I look forward to giving my daughter Violet that same experience,” he said.
MMC physicians and the CCM staff are in the first stages of reaching out to eligible Medicare patients with two or more chronic conditions. A few examples of common chronic conditions include heart failure, COPD (chronic obstructive pulmonary disease), asthma, kidney disease, chronic pain, mental health issues, insomnia, and diabetes. Contact the Chronic Care Management program at (870) 460-3561 to learn more about the program.