Starting soon, a nurse navigator will meet with each patient after a visit to summarize care and plan for follow-up communication with patients between visits.
“In the beginning, losing a dedicated office space was challenging for many providers to accept,” Dr. Manzi says. “That changed [after] we started seeing patients and realized the value of open access [to] other providers to support the many aspects of care a rheumatologist normally tries to take on individually, whether the patient is having difficulty taking their medications, suffers from depression or even struggles to get to their appointments.”
A Coordinated Care Model
To create the Autoimmunity Institute, Dr. Manzi and colleagues borrowed approaches used in other AHN team-based, integrated care models for chronic conditions, such as diabetes. Dr. Manzi created a similar pathway for autoimmunity. Here are some important steps in the process:
- Focus on two autoimmune conditions: In the beginning, the team focused on rheumatoid arthritis (RA) and inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis. Patients with these diagnoses being seen at AHN were tracked and placed on the care pathway.
- Create a team: Pharmacists, behavioral health, consultants, nurse navigators, dieticians, and social workers were identified and trained to work together to manage the panel of patients with the physicians and advanced practitioners.
- Stratify patient risk: RA and IBD patients at highest risk for poor outcomes were identified based on higher acuity disease and social determinants of health, such as depression and poverty, in an effort to allocate resources effectively.
- Develop clinical protocols: The team developed standardized treatment protocols based on published guidelines and best practices to minimize variability. These protocols include first-line treatments, how to monitor efficacy and when to move to a different treatment.
- Align formularies: AHN is also part of an integrated payer network. Thus, the team was able to align medication formularies with the payer, avoiding the setbacks associated with prior authorizations to increase access to medications for their patients.
- Develop a customized care pathway for each patient: With standardized treatment protocols in place, care pathways were tailored to each patient based on their specific needs, such as transportation limitations, behavioral health needs and financial constraints. The pathways enabled the appropriate team members to engage as needed and manage patients during on-site visits, as well as by phone in between visits.
- Coordinate the care pathway electronically: Care pathways were embedded into AHN’s electronic health record system to facilitate care coordination with all team members.
- Invite the patient to be an equal participant: Patients were introduced to the integrated approach to help them understand they might see multiple providers during a single visit, as well as how their providers work together for their care.
“It really comes down to moving away from episodic care with a physician to managing patients within a continuum of care [in which] the patient is interacting with different members of the team during and in between visits,” Dr. Manzi says.
