At Williamson Health and Wellness Center in West Virginia, we understand the importance of chronic care management for patients, our practice, and the health system. When not effectively controlled by providers and patients themselves, chronic conditions put a hefty burden on the health system by over-utilizing care services that generate sky-high costs.

To avoid this problem at our practice, we implemented a team-based Chronic Care Management program in 2012. With the Central Appalachian Health Alliance, we received a grant from Duke University’s CMS Health Care Transformation project to test the effectiveness of using community health workers to manage the care of high-risk diabetic patients. That program’s success led us to expand our care coordination network and provide community health workers to all high-risk patients with chronic conditions.

Our program has produced phenomenal results. We use the Aledade app daily to identify and prioritize high-risk patients. We’ve expanded practice hours and implemented an after-hours phone line. And, we’ve improved patient information and care coordination with the local hospital.

One recent example hit home as evidence that our Chronic Care Management program is making a real difference.

One of our patients with chronic obstructive pulmonary disease (COPD) had a habit of seeking care at the emergency department (ED) once or twice a week. This patient had serious anxiety about his COPD and saw emergency care as his only option when he had trouble breathing. Due to his condition and anxiety, we decided to enroll him in our Chronic Care Management program.

Once enrolled, the patient received additional care services, including weekly home visits from community health workers – who reduced his anxiety, taught him how to better manage his COPD with practices like breathing exercises, and helped him understand resources other than the ED that he could use when he needed outside help. Community health workers are absolutely vital to our program, working on the “front line” to deliver care, assess risks in patients’ daily lives and homes, and educate patients on self-management.

In addition to those visits, the patient received comforting check-in calls every Friday – when he typically went to the ED – from our practice staff. We also set-up a standing order of Solumedrol, which had proven effective for the patient, at the ED should he seek care there.

The good news: he hasn’t been back. His results have been stunning. The patient who previously went to the ED up to twice a week has now gone six weeks without returning. The Chronic Care Management program has had a huge impact on his life and avoided a dozen ED visits, also easing the strain on hospital providers and slashing the cost of care.

While this is an exceptional example of success, we’ve seen team-based Chronic Care Management work time after time for patients with all forms of chronic conditions. We look forward to sharing more turnaround stories with you!