“I will live in the Past, the Present, and the Future. The Spirits of all Three shall strive within me. I will not shut out the lessons that they teach.” ― Charles Dickens, A Christmas Carol
The holiday season is upon us. People around the world lean into various traditions that have a common theme of love, light, giving and receiving – even if only kindness – in some form. Except for Ebenezer Scrooge, the fictional protagonist in Charles Dickens’ “A Christmas Carol”. The main message Dickens delivers in the classic tale is centered around kindness to everyone. Dickens wrote about greed, poverty, health, humans, and our relationships with others.
As the new year approaches, this is a great time for reflection on experiences of the past and being intentional about changing the future. That is why I bring you this tale of a patient journey, from the perspective of the care manager working the case.
Years have passed since that December day. The holidays were approaching, which meant our days in the office would be limited, especially with the blizzard rolling in.
The case was a patient flagged for multiple readmissions. Cases like these are challenging because patients are transitioned from a hospital to a nursing facility, with accountability and care management occurring at both facilities and various levels of care. As a care manager for the payer, I needed to review data stored in various software systems used by various teams.
- The payer’s care management software: The patient was an African-American male in his thirties, with an active Medicaid policy.
- The payer’s “other” care management software: The patient had a history of diabetes and multiple readmissions for hypervolemia (fluid overload).
- The utilization management software:
- The admission and discharge notes were binary images of the scanned paper chart sent from the hospital to the managed care payer via fax. During each hospital admission, those were sent for concurrent review every few days.
- Since the reason for admission was fluid overload, I referenced lab values related to kidney function. After a few minutes looking for labs and discharge orders, and several right-clicks later, I found the lab observation I’d been searching for. At discharge, the Glomerular Filtration Rate (GFR) was in the twenties. There was not a diagnosis indicating end-stage renal disease (ESRD), only hypervolemia.
The first admission had a date of service nearly a year prior, when he was discharged to a skilled nursing facility following the hospitalization. The free text documentation noted the patient presented homeless upon admission. The patient could not be discharged home because he did not have a home, and still required follow up treatment, including a referral to a nephrologist.
The narrative of a middle-aged homeless man with fluid overload continued. His treatment plan was for diabetes and medication management, as well as skilled services. The referral for nephrology was there, however the appointment never happened. Instead, the patient cycled to and from the hospital and nursing home for nearly a year.
The next step was to call the patient at the facility, check in with him, and do a standard assessment. We talked to the care team and shared the objective findings of my intake assessment. The nephrology appointment was scheduled within the week and the facility was monitoring the patient. Human experience was a priority. I learned details like he grew up in the inner city and stopped going to school in the 6th grade. At that time, he was living with his father, who died from diabetes. He became homeless after his father’s death. His kidneys started failing from uncontrolled diabetes while living on the street.
These details are significant in understanding the patient. Comfort was a priority. He wore a hospital gown for the past year. His only clothes from the first admission didn’t make it to the nursing facility. A church nearby brought the patient a basket full of holiday hope and new clothes from the nearest Big & Tall store that same week.
Within thirty days, the patient had a fistula placed and dialysis began. He had transportation to and from his appointments. Over time, he qualified for disability income, moved to a lower level of care, and got his own apartment with waiver services.
Health Equity and Social Determinants of Health (SDOH) are high priorities in public health policy. Equity is a measure of quality. Managing ESRD and Skilled Nursing Facility (SNF) levels of care are top expenditures to payers. Financial claim and clinical data have a common standard defined for both payers and providers who are mandated to have data accessible in the form of Fast Healthcare Interoperability Resources (FHIR) via Application Programming Interfaces (APIs). Regulations are expanding data exchange between payers, providers, and patients via FHIR APIs.
This patient’s journey could have been different with data exchange via FHIR APIs. With FHIR, the objective data observations come to the surface, like a GFR in the twenties, rather than buried in a minefield of free text paper faxes. The patient’s referral for nephrology would be in place at discharge. Homelessness, poverty, and education would be a Z-code indicating SDOH data points so resources could become available earlier in the wellness journey.
God Bless Care Managers, every one!
“It is always the person not in the predicament who knows what ought to have been done in it, and would unquestionably have done it too.” ― Charles Dickens, A Christmas Carol
While this tale had some form of a happy ending, it also reflects the failure of an entire healthcare system. We must continue to reflect on these experiences and learn from them. Payers and providers must both prioritize establishing a form of data exchange that is beneficial to all, including the patient. As we approach the new year, my hope is we can continue to work together to reshape the future.