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How do we ensure that care managers and care coordinators really use their energy to help our patients get the best care they need?

Over and over again, we've seen well-intentioned efforts by these team members, seemingly countless hours on their part, lead to no significant value added. Unfortunately, the system seems to be stacked against them.

We've all seen this happen over and over again: our patients have someone assigned to assist in managing their care, by virtue of their insurance plan, through an emergency department discharge program, after going home following surgery or an admission, or through any number of other mechanisms.

We see lots of documentation in the electronic health record -- long extensive notes that read like works of imagination, flights of fancy, an aspirational set of goals that somehow never seem to come to fruition. "Patient will be scheduled for all interim referral appointments; patient will be connected with resources in their community; patient will remain compliant with their medications; patient will be educated on signs and symptoms of exacerbations of their health conditions; patient and their family will be made aware of symptoms that should prompt them to call their doctor for further advice."

Outreach to help patients see the providers we've referred them to, or to go through with the imaging and other tests we've set up, often seem like the best laid plans of mice and men. Several times during recent office visits, I've made a number of critically important referrals and written orders for procedures, but although the patient already has a care manager or care navigator assigned to them, once the patient leaves our office, no connection is ever made.

Several notes in the chart say, "Multiple attempts were made to call patient on their home and on their cell phone numbers, but we were repeatedly unable to reach patient; left messages for them to call back." And when the patient returns to my office, nothing has been done. "No one ever called me," is what we hear.

I often think that when one of these team members calls the patient -- and in fact when any member of the healthcare team calls them, whether it's me, a nurse from our practice, an appointment scheduler, or someone trying to set up a CT scan -- that we should probably do a better job of using caller ID to let patients know who it really is.

Instead of "generic hospital calling," perhaps the caller ID could say, "This is Bob from the dermatologist's office, that specialist that Dr. Pelzman referred you to so that you can get that skin rash checked out. I know it has really been bothering you; please call us back as soon as possible so we can find the best time for you to come in, and when you call back let the people who answer the call know that you're returning our call to make an appointment to come in and see us." Sure, probably a little longer than the phone company will allow, but you get the general idea.

Most of my patients tell me they don't answer the phone when they see the hospital calling because they think it's someone after them for an unpaid bill. Perhaps we need to do a better job of introducing everybody and letting patients know who everybody is, who's going to be reaching out to them, and why they're doing that.

If patients were reassured that this is all in their best interest, that "After your visit today, someone's going to call you to set up your colonoscopy, go over your medications, and schedule a follow-up appointment with your cardiologist," and everybody knew that and they were all connected up front, we might have a much better chance of success.

These roles have enormous value to add to the care of our patients, helping make sure that what we think should happen for the patient between visits actually happens, actually gets done. But when there's a lot of effort with no positive outcome, it can be frustrating for everyone involved.

There are certainly technology solutions that could help, whether it's a chatbot, a text to their phone, a better portal message, or some other way to ensure that everybody's connected, and I don't mind having people think creatively about this to help find solutions. When this doesn't happen, when we see endless notes in the electronic health record stating that we tried to reach a patient, and the patient says no one tried, and then the patient ends up going to the emergency room for something they do not need to go there for, then nobody wins.

Maybe it's unreasonable to expect everyone to introduce themselves, when they're all remote, when they're all in rotating roles, when it's never the same person twice. Maybe, instead, in the future every patient will have a virtual assistant assigned to them to help navigate their healthcare in between the times they are with us in the office.

Their role could include ensuring that patients understand their posted lab results; have all their questions answered; get connected to their pharmacy; have insurance authorizations taken care of; set up all of their appointments to see their specialists and manage their healthcare maintenance tasks; and help them find local resources including mental health, healthy food options, access to exercise and housing, and transportation to all their appointments. The assistant would be someone who can be there when the doctor cannot.

For now, it would be nice if, at the end of our office visit, we can feel confident that the tasks we think are necessary for each and every patient to complete between the time they leave our office and the time they come back to see us again, really do happen. Then we'd all be a lot better off and a lot closer to that healthier place we all seek.

The path ahead could not be clearer.

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