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Coordinated care and patient engagement

Primary care practices must prepare for patient activation and care coordination

The healthcare breakthrough of the 21st century may not come in the form of a miracle drug from the pharmaceutical industry. Rather, it's more likely to emerge from the ways caregivers interact and motivate patients.

Characterizing patients as non-compliant has long been an excuse for physicians not fully engaging people, but that needs to change, according to Bruce Bagley, MD, CEO of TransforMED, an organization devoted to helping medical practices transition to the patient-centered medical home model.

"Getting people engaged in their own treatment and giving them the support that they need to manage their chronic conditions, and getting their family involved in helping are all key aspects," Bagley told attendees at MGMA's 2014 annual conference here on Monday.

Skills that office staff need to ramp up around patient activation include motivational interviewing, shared goal-setting, informed medical decision-making, home monitoring and between-visit outreach.

Practices also need to be IT-enabled to handle and share clinical information along with corresponding financial information.

Nonetheless, Bagley noted that patient engagement activities would continue to be extremely important, as practices get more involved in value-based care models such as accountable care organizations.

That will mean primary care taking a central role in care coordination. For example, it makes no sense to structure an ACO that requires practices to refer patients to a specific cardiology group. If there's another group offering the same services at much lower cost, that option should be available for proper care coordination.

"The more we can get people used to the same coordinator of care over time, the better it works," he added. "However, if organizations don't have an explicit plan to engage patients in the ACO, then they'll have trouble."
 

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