BECAUSE OF AGE, infirmity,
socioeconomic issues and
more, effective treatment calls
for personalized plans vs. a
population care roadmap, says
Judy Carden, a registered nurse
and certified diabetes educator
who is a diabetes clinician
for Sharecare.
for personalized plans vs. a population care roadmap, says
Judy Carden, a registered nurse and certified diabetes
educator who is a diabetes clinician for Sharecare.
“I work with patients who have diabetes while they are
hospitalized,” Carden says. “A lot of them also have COPD,
so they are in the hospital for that or another illness, alongside
anything that’s happening with their diabetes. We can get
a lot done in the hospital setting as far as disease management,
and that is where we have to work on education and
preventive care as well.”
Patients come to Carden via referral from doctors and nurses,
and the care team reviews the patient’s medical history with
her. That includes not just chart numbers, but family history
and other information if it is available. The growth of a
case-management system for diabetic patients, as well as
those with COPD and other chronic diseases, is a step in the
right direction but also just the first wave of a process which
mostly lies outside the facility’s walls, Carden says.
“With the chart we can get a picture of their A1C and see
if we can get that under control,” she explains. “We
have clinicians in the hospitals who are doing this kind of
case management when those patients come in, and then
we try to get them connected with outpatient therapies, or
education, so that everything that’s done to get conditions
under control during hospitalization doesn’t go away once
they are discharged.”
Research indicates that interaction with providers can and
does lead to reduced readmissions and better patient
outcomes, she says, adding that engagement also lowers
healthcare spending on these patients. But it requires their
initial and ongoing cooperation, which is why she says
education may be the most important component of any
population health management strategy.
“All the research, all the literature, points to that,” Carden
says. “If patients know more, they follow directions better
and get things like blood sugar under control. They can
improve dramatically in just two or three months but
need encouragement to keep up with the regimen. It’s
much easier and cheaper to prevent a condition from
happening, or worsening, than it is to treat something
they already have.”
Population Management Allows for Targeted Treatment
Treating any or all of these conditions effectively requires
the adoption of a population health management, or PHM,
model. This is defined as a focused approach to improving
the health outcomes of a specific subset of patients sharing
similar health challenges or conditions. Some ways these
groups can be further divided is by:
• Healthcare system or insurance plan
• Geography/location
• Specific disease
• Other unique and shared characteristics
The rise of the PHM model has accompanied the ongoing
move away from fee-for-service patient care and toward
the value-based model, which rewards twin goals: cost
control and improved outcomes. Participants include
insurance providers, quality improvement agencies,
healthcare systems, and healthcare providers, all of whom
are applying public-health concepts to chronic disease
management by obtaining and using data to hone in on the
most effective methods that achieve the desired results.
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