Longitudinal Care Management for Improved Chronic Disease Outcomes Corewell Health

Chronic disease management is a key opportunity for all health care systems interested in value-based care success. Patients with uncontrolled diabetes are at increased risk of poor clinical outcomes, which are compounded when other chronic conditions, such as hypertension, also exist. Many of these patients are unequipped to self-manage and have trouble establishing health behavior goals that may help bring their diabetes under better control. Care managers embedded in primary care settings have a unique opportunity to partner with patients to create space for an honest dialogue about the barriers and challenges impeding their ability to achieve optimal health.

Adopting the Scaled Agile Framework for Enterprises (SAFe®), Corewell Health developed crossfunctional teams comprised of individuals from operations and digital services that quickly adapted to changes, new insights and information, embodying transparency, alignment, respect for people and continuous improvement. These teams aligned around a common purpose, vision and understanding focused on the problem first, and then allowed the best solution to emerge through iterative end-user feedback and person-centric development. With this new collaborative agile approach, the teams were able to maintain continuous delivery of viable, desirable, feasible and sustainable innovative solutions to address these health opportunities.

In January 2020, the Corewell Health care management team started to redesign a longitudinal care management (LCM) program with a plan to identify, engage, and support patients with chronic diseases more effectively, starting with diabetes management. Evaluating learnings from over 10 years of care management experience, the design team mapped a pathway focused on a structured connection of interventions. Full implementation of the redesigned LCM model occurred in January 2022.

Central to our longitudinal care model’s design is the ability to identify patients who can benefit from enhanced self-management skills and a patient-centered program design, matching interventions to the patient’s stage of change. Care managers taking a whole-person approach to patient care help patients set realistic goals and build on their initial successes in behavior change. Over time, this momentum can have a significant impact on clinical outcomes, while respecting a patient’s autonomy to determine what works best in the context of their own health care journey.

Identifying a focused patient population is a good first step to matching that population with an intervention tailored to their needs. Personalizing an approach creates systemic design that fosters effective LCM models. Risk stratification can also be a helpful tool to identify patients at risk for poor outcomes or utilization of high-cost care. Corewell Health defined their initial focused patient population as patients of internal primary care providers (PCPs) with risk contracts. A flag, called the “Blue R” was established within the electronic health record to delineate these patients. Additional builds provided proactive patient lists to identify patients with the Blue R and a Hemoglobin A1c (HgbA1c) of 8 and greater. Once the LCM intervention and workflows were established, customized Epic Compass Rose tools were built to facilitate longitudinal documentation by the care management team.

Implementing this disease management effort has yielded positive clinical and financial outcomes. Patients have achieved better control of their diabetes and reduction of A1c and systolic blood pressure can be observed. These clinical improvements bode well for patients' longterm health and health care resource utilization.