Sometimes, one of the most valuable members of the care management team isn’t in the practice at all.

For example, take a patient we enrolled in chronic care management in 2015. The patient was nearly 80, and living with a number of chronic conditions – starting with some pain in her ribs. We enrolled her in CCM so we could find the cause of this rib pain, control it, and hopefully help the patient stay independent.

Aledade teaches practices how to identify the patients who would benefit the most from the Chronic Care Management program. They encourage CCM for high-risk patients with multiple chronic conditions, high-risk factors, and poor symptom management. Most of all, they encourage practices to help patients improve their self-management skills, so they can live as independently as possible.

At the first appointment for our patient, I met one of her two daughters. We ran through all the preliminary steps, and set up a care plan. That’s when I learned that the patient lived with her other daughter. That daughter would be our point of contact.

From the beginning, this mom and her daughter called me with any needs they had. I helped the patient and her daughter set up studies, appointments with specialists, insurance referrals and communication with the patient’s primary care physician. I made sure that we had all of the communications and correspondence from specialists that we needed, and I kept the patient’s list of medications updated.

Aledade’s Care Management model emphasizes how important it is to have coordinated care, especially for high risk patients. They train practices on how to connect patients to the right care at the right time and for the right reason. Through this care coordination, we can close the gaps in care, making it simple and continuous for the patient.

In the process of our care management, I learned a lot about our patient.

But I was also learning a lot about her daughter. She was working three jobs at once – one full-time, and two part-time. Not to mention her fourth job as mom’s caregiver and main source of support. I knew how hard she was working. I could hear it in her calls and messages, which always came at the break of dawn or late into the evening. I made a point to respond to every single one.

Aledade’s Care Management holds the patient and their family at the center by emphasizing the importance of trusting relationships between the practice and our patients. The whole model encourages us to focus care around the patient’s needs and concerns.

One morning in June, my phone rang. It was the patient’s daughter – our care team MVP. I knew that they were on the search for an apartment that was just a single level, since it was getting tougher for mom to go up and down the stairs. Until then, every morning and every evening, the daughter would help her mom up the stairs and down – careful to avoid any falls, with all of the back and knee problems her mom had.

The night before, though, had been different. The daughter noticed it right away. She told me her mom had been “very winded” – much worse than normal. It took her a lot longer to recover from the walk. The daughter didn’t notice any chest pain or shortness of breath, but that morning, her mom was much more tired than usual.

I asked the daughter if they’d be able to come to the office that day. She said yes – she’d just need 30 minutes’ notice so she could leave work, pick up her mom and make the drive over.

Early that afternoon, our patient’s primary care doctor welcomed them in – the patient was diagnosed with new-onset congestive heart failure. We started her on a diuretic and scheduled an urgent follow-up with a cardiologist. By the end of it, we avoided what probably would have been a costly and frightening visit to the emergency room.

Aledade encourages care managers to proactively educate patients and caregivers on managing symptoms – not to wait until they become a problem. They advise practices to keep open lines of communication with their patients, so the patient can contact the practice as soon as a symptom becomes a concern. Quick and clear communication can help the practice and patient get the appropriate triage, ultimately reducing how often patients and their families have to visit the practice or a hospital.

There are a number of effective ways to do this. One way is to set up same-day appointments in the office. Another is to open a phone line for patients that’s available 24 hours a day, 7 days a week. Aledade always reminds us how important the relationship is between the practice and the patient.

Today, our patient’s follow-up is continuing. She’s getting better. And our care team all-star, her hardworking daughter, is our care management team’s key contact. Her mom is lucky to have her around. Our practice is, too.