I can’t get “Jason” off my mind. Jason was the young man I met a couple of weeks ago who had the life-changing misfortune of suffering multiple paralysis following a tragic diving accident. Jason is now completely dependent on the support of caregivers to carry out activities of daily living (ADL’s).
I asked Jason, “With all the technology now available to help manage your health, what solution do you find most useful?” He didn’t hesitate in his answer. Jason looked at me and said, “If I need to make a phone call, use an app, or send a message, I need to have a caregiver reach into the bag on the back of my chair and hand me my cellphone. Most of the time I can’t access any of this technology without someone’s help to get it and use it on my behalf.”
What is the number one thing he needs from his physicians? To be on the same page.
Our experiences with high-needs patients, like Jason, and the complex care teams that support them have shown us that technology is a critical component of a successful model, but it alone can’t do the job. Jason’s story demonstrates that, while the complex patient sits in the center of the care team, the patient’s personal services and accountable caregiver supports are critical for quality of life, plan adherence, and even survival. The real need for technology is not necessarily to engage with the patient but rather to enable the diverse and dynamic team surrounding the patient to communicate, coordinate, and actively manage the care plan together — to meet Jason’s greatest need and be on the same page.
So, what’s needed for complex care management?
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Multidisciplinary team: care manager, physicians, specialists, community resource specialists, behavioral health providers, pharmacists, administrative/project management resources;
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High-touch approach with patients (frequent interactions, face-to-face) and patient empowerment (education for self-management, digital access to team & plan, etc.);
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Trust built amongst the care team and with the patient and their family;
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Assessment of functional status, behavioral health, and social service needs and incorporating these components in the care plan;
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Patient priorities reflected in the care plan;
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Near real-time notifications of significant events (hospital and ED admissions);
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Laser focus on the coordination of transitions and immediate post-discharge care;
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Treat informal caregivers like royalty — they can be the most valuable resource;
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Continually assess program and improve.
Where technology fits in the mix
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Get everyone on the same page
All members of a care team, regardless of role or setting, need to be able to easily access the up-to-date plan of care. This reduces duplication and errors and has a major impact on patient and caregiver satisfaction.
Manage a high-volume of diverse activities
Complex patients have a wide variety of needs ranging from medications and medical procedures, to durable medical equipment and transportation, substance abuse support and caregiver scheduling. The volume of activities is extremely high and one small item falling through the cracks can impact a patient’s survival. Care teams need technology that brings a “project management-like” approach so they can easily keep track of the comprehensive list of tasks, identify who is responsible for what activities and know where to focus.
Implement evidence-based protocols and hardwire operational best practices
Research suggests that specific pathways or processes can positively impact outcomes and reduce costs. Teams need to be able to access these evidence-based protocols and best practices, assign the different steps of a process amongst a team, have visibility into the current “state-of-play”, and have confidence in the execution of all steps.
Healthcare technology companies need guideposts to deliver real value
Jobs-to-be-done Framework
Technology exists to help people get their jobs done. At ACT.md we’re building technology based on the jobs-to-be-done framework, a tool for evaluating the circumstances that arise in patients’ and providers’ lives and understanding their motivations.
Within this framework, we’ve learned that engagement for patients, providers and payers can be quite different. For example, the “high-needs patient” Jason is completely dependent on caregivers to live his fullest life possible. What is the job Jason is trying to do? When he wakes every day, he wants to have as many freedoms as possible to move, eat, and function alongside the people he loves. For other patients, they want to know, “How do I get better?” For others, “What’s the plan for managing this condition to live the fullest life possible?”
For providers, the jobs can be very different. What we’ve learned is that providers want to streamline workflows and leverage their whole staff to do the job of team-based care. Oddly, most of the technology purchased by provider organizations today has one important job – to help providers get paid for their services. Certainly providers who are delivering high-quality care deserve to get paid, but there is much more at stake for all members of the care team.
The transformation from a fee-for-service world to value-driven, team-based models of care won’t be accomplished with legacy technologies that focus on encounters rather than comprehensive care plans. Framing the discussion in the context of the jobs-to-be-done model is helpful to guide companies to develop solutions that can truly make an impact and deliver value.
The Short Story
I am the founder of a company that has technology at the core of our offering. However, I also have the personal and professional experiences that have given me the knowledge that technology alone will not do the job. Technology is absolutely part of the solution to help high-needs patients live fulfilling lives, however, team-based care delivery models, complex care management programs, and caregiver involvement are also required components to get this job done.
Photo: Amanda Millis, CDC
