Chronic illnesses and chaotic lives go hand in hand.

That was the takeaway from a recent survey published in the Journal of General Internal Medicine, which asked patients in a care management program to list their primary concerns. More cited family and financial issues than their own health. And these high-risk patients said the services they most valued from their own care coordinators were those that helped them gain a sense of control over their lives.

At Mission Health Partners in North Carolina, a network of eight hospitals and more than 200 physician groups, care coordinators take a 360-degree view of patients' lives.

“Obviously, there's a medical management piece as well," says Katie Bartholomew, manager of clinical operations for care coordination for the community-based accountable care organization (ACO). “But we spend a lot of time trying to identify social barriers to better health."

And as care teams identify broad problems to be solved — from housing to language barriers to legal troubles — Mission also tracks and measures the solutions.

“I know that every ACO I talk to gives, at a minimum, lip service to the concept of social determinants," says Rob Fields, M.D., Mission Health's medical director. “But what we do differently is hold our care coordinators accountable for closing social determinant gaps."

From phone to home

To address the drivers of health, Mission's care coordinators perform as command centers, ensuring that information flows between patients, providers, and community resources.

With most of their work taking place by phone and messaging via its electronic health records (EHR) system, the coordinators work in tandem with community paramedics, clinical pharmacists, and other members of broad care teams.

“If we feel like a patient needs to have eyes-on," says care coordinator Lisa Swaim, “then the community care medics and pharmacy techs can go into the home to do a very detailed assessment of what the patient is doing versus what we think they're doing, so that we can let the doctor know specifically what's going on."

That's what happened when one Mission Health patient, who suffered from paralysis on one side of his body, slipped in the bathtub and injured his good side. His caretaker wife nearly despaired. If she couldn't lift him, she couldn't take care of him. And then what would they do?

Within hours, Mission's care coordinators sent a paramedic to the house. He determined that the man had a fractured fibula and arranged for him to be transported to a hospital.

What's more, the paramedic recognized that this man's wife needed mental and emotional support as well. So the care coordinators provided stress management tools and kept in contact with her to make sure her condition was improving. Stabilizing her health meant that her husband could come home, rather than be sent to a long-term nursing facility.

Sharing the data

Much of the sharing of information from physicians to medics and pharmacists back to physicians happens automatically at Mission. As medics upload their reports to the EHR, says Swaim, “We're able to look at that and see exactly what happened, vital signs, and areas that they feel need to be addressed … so that when we call to follow up, we've got that [information] in front of us."

And so does every other agency required to restore stability to a patient's life.

“We have a network of community partners that are actually engaged in [our digital care coordination] tool," says Fields. “They log onto the tool, just like a provider or a nurse would. When they receive that referral for the patient, they have line of sight into the care plan. And not only to their piece of the care plan. If I'm a housing agency that's tasked with finding stable housing for this patient, I can see that. I can also see that the legal aid agency is working with them. I can see that we are working on transportation issues."

Ever-evolving technology is expanding that information flow to include patients themselves, bringing even more detail into the coordinators' understanding of their patients' lives. New tools are putting control directly in the hands of patients to report their own vital signs, symptoms, medication adherence, and progress back to the healthcare system.

In a pilot program at Mission, for example, diabetic patients are using a smartphone app to send secure messages, receive reminders of tasks in self-care, input blood glucose levels, and record their daily diets and exercise. That patient-reported data is then converted into a graph so that both patients and care coordinators can track their progress at a glance.

“Sometimes the community care medics will upload a picture of a diabetic patient's log, be it blood pressure or blood sugars, heart rates, whatever. And it's just the biggest mess," says Swaim. “So, having those numbers in a graph, and being able to track them over time, that's part of helping them take control and feel like they have power over their condition; to see, with their own eyes, that they are making a difference."

Building trust

Technology can only do so much, however.

What begins with understanding and addressing the full context of patients' lives grows into trust between patients and their care teams

“The connections and the relationships with patients," says Fields, “are ultimately what end up making the difference in the chronically ill. And that's been demonstrated over and over again."

That has been the outcome for the patient with the broken fibula. Now, he's living at home, in a house now outfitted to keep him safer — without overwhelming his wife.

"I was totally incapable of handling this myself," she says. "I never could have arranged it, and all the complications, and government, and money ... It's like some sort of magic thing they did. You need somebody with the skills they have."

Gale Pryor is associate editor of athenaInsight. Listen to Rob Fields talk about Mission Health ACO — and the expansion of care teams — on the Decoding Healthcare podcast. Artwork by Abigail Goh.