The 5 Characteristics Of Successful Chronic Care Management

posted by Dr. Richard Shinto, CEO, InnovaCare

on June 25, 2018

Health care leaders from around the country gathered last week at the annual AHIP Institute & Expo 2018 event in San Diego to discuss solutions to the many complex and deeply rooted challenges facing health care today.

And solutions are out there, explained Wharton professor Dr. Ezekiel J. Emanuel, a chief architect of the Affordable Care Act. During a presentation on the Institute’s opening day, he showed that in certain pockets across the country, health care organizations are making huge strides managing chronic care.

Emanuel also pinpointed five common characteristics shared by organizations successfully managing chronic care. I concur with Emanuel’s five traits, because I’ve seen them play out firsthand. For more than a decade, I’ve led one of our company’s subsidiaries to manage complex care in one of the nation’s most difficult and comorbid markets—Puerto Rico. Here are Emanuel’s five steps, with some added perspective from our unique market.


  • Identify high-risk patients. Identifying high-risk patients doesn’t always require high-tech tools. While we have successfully identified high-risk patients using software that tracks data to prevent an acute event, we also rely heavily on the intuition of our physicians who notice changes in patient behavior. But the latter is only possible when doctors have developed personal, one-on-one relationships with patients—an absolutely critical piece of care.
  • Embed care managers in primary care teams. This is one of the top keys to creating equity in health care. Care managers must be out in patients’ communities. In Puerto Rico, we’ve stationed coordinated chronic care teams in clinics from the sprawling, urban capital of San Juan to some of the island’s most remote locations. The goal here is to ensure patients can access this level of care, regardless of resources or access to transportation.
  • Empower care managers to close care gaps. In other words, give them equal access to data and equal power to create change. Care managers should not only be viewed within the culture as a critical part of the care team, but also have access to health IT systems to engage with the rest of the care team through the EMR or another interoperable platform.
  • Use active outreach to contact patients and improve compliance and access in case of complications. Nationally, the trend is that patient loyalty to a specific doctor is declining. This isn’t true in our market, where members still value personal relationships with physicians above other factors. (The island only recently passed legislation to authorize physician assistants.) To maintain this loyalty, our doctors must reach out to members on a regular basis, either via phone or face-to-face. In fact, thanks to this robust patient outreach infrastructure, we were especially well-positioned to bounce back from the devastation of Hurricane Maria; it proved to be one of our great emergency preparedness tools.
  • Educate patients about their illness, adherence and how to use the health system. This is especially critical in Puerto Rico, where a significant portion of our members have the deadly combination of high chronic disease rates and had little access to health care education. This means that chronic care treatment must involve the services provided by our clinicians and access to care coordinators, as well as excellent communication and strategic follow-up from the care team.

Finally, I’d like to reiterate Emanuel’s point that organizations successfully managing chronic care are leveraging technology, but the secret to their success isn’t a technological breakthrough. They haven’t built groundbreaking systems reliant on telehealth or blockchain. Instead, the major innovation has been following these five principles—largely dependent on simple human interaction and good communication—which can be scaled or replicated to form the foundation of high-quality chronic care anywhere.


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