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Response to Commentary

Dr. O'Toole nicely highlights key components of effective case management and identifies both gaps and opportunities in this increasingly important aspect of integrated health care. Building upon his commentary, I highlight additional factors that might enhance the effectiveness not only of case management but also of integrated care writ large.1

A primary care physician (PCP) myself, I nonetheless contend the PCP need not invariably be the first step nor the bottleneck of all patient care. Instead, a stepped approach starting with the patient (i.e., self-management) and moving up a ladder in which peers, medical assistants, health care professionals (e.g., nurses, pharmacists, social workers, psychologists), PCPs, and specialty physicians all have a specific role is at once a more rational and team-based approach. Evidence suggests that each of these six rungs of the care team can, with appropriate training and synchronization, provide a sum greater than the segregated parts. Thus, a first principle of case management is to not ascend higher on the ladder than necessary.

Too much patient care is clinic-based. A great deal of data gathering, monitoring, education, motivation, and treatment can be conducted without the large indirect costs of travel, time away from work or home, and waiting to see the clinician. Often we focus too narrowly on patients in rural areas as the principal beneficiaries, whereas patients in large urban areas may also have inordinate commute times and comparable work loss and sacrificed time costs. Probably half or more of office visits could be replaced by distance-based, technology-enhanced encounters.2 Thus, a second principle is to accelerate the movement toward more home-based care except in those situations where patient travel to a health care facility is essential (e.g., procedures, certain diagnostic tests, infusion therapy, or urgent conditions).

More patient care activities could be done asynchronously rather than in real time. These include collection and monitoring of patient-reported data, clinician-patient communication, and selected aspects of management. A related issue is the increasing amount of clinical work that occurs outside of face time with the patient, including electronic health record (EHR) documentation, review of the enormous volume of EHR data relevant to patient care, and electronic communication with patients and other providers. Although strategies exist for using a computer in the exam room, financing more time for these activities is essential so that the patient does not feel like someone eating dinner with a friend preoccupied with texting. Consequently, a third principle is to use patient time in a patient-centered fashion while assuring practices accommodate clinical activities not requiring the patient's presence.

The rapid acceleration of technology-assisted health care allows only for the articulation of several salient issues. One is tailoring the modality (telephone, televideo, Internet, apps) to the clinical task. A second is deciding upon the relative roles of simultaneous (in-person or by phone) versus sequential (e-mail, texting, voice mail) clinician-patient interactions. The latter must account for the heightened privacy concerns unique to personal health information. A third issue is the degree to which patient data and transactions captured or enabled by technology are separate from or incorporated into EHRs. A fourth issue is the degree to which proprietary concerns of vendors are balanced with the needs of providers and health care systems.

Key components are summarized by O'Toole and others, so only a few high-priority decisions are noted.1, 3 First, should case managers focus on a single common condition (e.g., VA TIDES program for depression) or a portfolio of several conditions (hypertension, diabetes, etc.)? Second, which patients warrant case management resources and for how long? Third, how does one select a resource (and avoid redundancy) when multiple options are available (e.g., when a hypertensive patient could have a follow-up encounter with a PACT nurse, telehealth nurse, or pharmacist)? Fourth, how is the explosion of asynchronous communication (viewing alerts from other providers, secure messages from patients, e-consults from specialists, multiple clinical reminders) optimally integrated into the work flow of practice? Fifth, how is efficient synergism between the VA and non-VA care of our Veterans achieved given the yet unfulfilled promise of health information exchanges?

The brief taxonomy of choices reviewed here is a promising indicator of how teambased care augmented by technology can transform health care that heretofore has been fragmented into coordinated longitudinal population-based health.

  1. Kroenke K, Unutzer J. "Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care," Journal of General Internal Medicine, in press.
  2. Kroenke K. "Distance Therapy to Improve Symptoms and Quality of Life: Complementing Office-based Care with Telehealth," Psychosomatic Medicine 2014; 76:578-80.
  3. Huffman JC, et al. "Essential Articles on Collaborative Care Models for the Treatment of Psychiatric Disorders in Medical Settings: A Publication by the Academy of Psychosomatic Medicine Research and Evidence-based Practice Committee," Psychosomatics 2014; 55:109-22.

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