Leveraging the Care Team to Achieve the ‘Triple Aim’

As healthcare shifts to value-based care and other payment models, the focus on patient-centered care is gaining more attention, moving the focus away from throughput toward improved quality and patient experience.  SoNE HEALTH has developed its population health programs to provide wrap-around care for our patients that compliments the work of the Primary Care Provider (PCP).  Establishing a multidisciplinary care team can address all aspects of the patient’s care and helps to achieve the Triple Aim – better care for individuals, better health for populations, at a lower cost of care.  Acting as an extension of the PCP office, the care team provides support to their patients between visits, coordinates referrals and communications with specialists, facilitates smooth transitions of care throughout the continuum, and provides necessary education to the patient that reinforces the plan of care.

To improve outcomes for our diabetic patients, SoNE HEALTH kicked off its newest initiative with a Diabetes Management program facilitated by ambulatory clinical pharmacists. The patients in this program are categorized as rising risk, who have elevated Hemoglobin A1c’s (8.0-9.5%) but with no significant utilization of inpatient or emergency room visits. The pharmacist completes a comprehensive medication review, reviews the medical chart for quality gaps in care, and identifies any barriers with medication adherence.  The pharmacist will forward recommendations for medication changes to the PCP for consideration, and if accepted, the PCP will place the orders.  The pharmacist will also help to facilitate referrals to close quality care gaps if needed (diabetic eye exam, nephropathy screen), and provide education on diabetes, the related complications, maintaining a healthy lifestyle, and medication use.  This culminates in the creation of a self-management action plan for the patient to reinforce the teachings and care plan.

For the moderate- or high-risk patients, for example, those with multiple comorbidities or advanced illness with inpatient admissions or other high-risk indicators, SoNE HEALTH offers a Chronic Disease Management program and Complex Care program.  Similar to the pharmacist program, the goal for Chronic Disease Management is to provide condition-specific assessments and education in a bootcamp style forum. Both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) work with these patients to provide an overview of the disease, complications, common medications/treatments, and planning for what to do in an urgent situation. The PCP-established care plans are also reviewed to ensure patient understanding and adherence.  Complex Care is a more longitudinal program with episodes ranging 60-90 days with an RN.  The goal is to reduce utilization, conduct goals of care conversations, create a shared care plan, and assist the PCP with beginning advanced care planning discussions.  Both programs will engage the pharmacists for medication consults, as well as other care team members as needed.

Social workers, Post-Acute Care Managers, and Care Continuum Specialists also play a role in a robust care team model. A Licensed Clinical Social Worker (LCSW) helps manage the patient’s behavioral health needs or can bridge the gap for a psychiatry referral.  The Post-Acute Care Managers will help direct patients to the appropriate site of care and will work with a network of preferred Skilled Nursing Facilities (SNFs) to manage patients during a short-term rehab stay.  Care Continuum Specialists follow up with patients discharging from an inpatient facility or emergency department to ensure a smooth transition back home – follow-up appointments are made, discharge instructions are reviewed, home health or other services are engaged, and medications are reconciled.  To assist with finding community resources, managing handoffs between internal and external care team members, and addressing social determinants of health, Community Health Workers (CHWs) support all team members to coordinate the patients’ care. Together, the care team supports the patient holistically while working with primary care and specialists to optimize the patient experience.


Jessica LeTourneau, MBA is Manager, Former Quality & Performance at SoNE HEALTH