In addition to credibility issues, traditional healthcare providers, including hospitals particularly, but physicians and nurses as well in many cases, are likely to have continuity challenges in making health management work, whether for patients or employees.  Sickness care has long been discontinuous for most patients, while health management requires regular contacts and continuous tracking of consumers’ responses thereto, changes in behavior, in objective health indicators, and in the value produced thereby.

While primary physicians are, in ideal circumstances, “medical homes” for consumers, they provide continuity through regular visits, for annual checkups, immunizations, and in some cases, health management.  Some primary physician practices, such as those that are part of the MDVIP retainer practice organization, include continuous tracking on patient-specific web pages, that both patients and physicians can access to monitor and evaluate progress in health improvement and maintenance efforts.  The growing number of physicians that offer online ‘consultations’ enable continuity beyond that possible through visits alone.

Nurse practitioners engaged in health coaching as part of proactively focused retail clinics, offer a degree of continuity beyond that of clinics offering just episodic sickness care, though unless they serve as patients’ medical home, will not usually know about patients’ use of primary physicians and specialists, hospitals or ERs.  The one major proactively-focused RediClinic chain of clinics has recently added a “Cholesterol Challenge” program of screening and coaching by its nurse practitioners, for example, involving continuous tracking as well as coaching. [“RediClinic Offers New Low-Cost Cholesterol Program to Help Consumers Take Charge of their Health” PRNewswire.Com Aug 7, 2007]

Hospitals are easily the least continuous provider that might be involved in health management (HM).  In most cases, the “patient experience” they deliver begin and end with admission and discharge.  There may be some minimal pre-admission registration and preparation, and discharge instructions, though these often leave patients poorly prepared, as they see it, for their own efforts in follow-up care. [“Many New Moms Feel ‘Unready’ at Hospital Discharge” Forbes.com Aug 7, 2007]  Hospitals may have records of the care they have provided to patients, but generally know nothing about care provided by other hospitals, ERs, specialists or primary physicians.

On the other hand, the potential for hospitals to promote post-discharge care is widely recognized.  The American Heart Association and the American College of Cardiology recently issued guidelines recommending post-discharge care of chest pain and heart attack patients.  These include additional testing, risk stratification, and preventive therapies.  They do not stipulate a role that hospitals might play in promoting such care, but certainly leave open a way for hospitals to offer such follow-up care, or at least check if patients have arranged for it. [“Experts Refine Heart Attack Treatment Guidelines” MSNBC.msn.com Aug 6, 2007]

The problems with doing anything past discharge include potential objections by medical staff physicians, who would generally prefer providing such care themselves.  Moreover, merely checking to see if patients are following up their discharge by seeing a physician for additional care puts hospitals at some legal risk when patients do not, while generating no revenue for the additional contacts required.  If a hospital follows up discharged patients and asks if they feel well-prepared to manage their condition at home, and the patients answer “no”, what is there to do that does not cost money while generating no added revenue?

Of course, some hospitals have taken on such follow-up despite the legal risks and lack of revenue.  York (Maine) Hospital, for example, has assigned inpatient nurses to make visits to patients in their physicians’ offices prior to discharge, and where possible used the same nurse that provided their care to follow-up with post-discharge calls, rather than using a nurse the patient doesn’t know.  Nurses are assigned patients based on the communities in the area where they live, so may have continuous care of patients even on repeat admissions.

When hospitals originally initiated HM services in the form of “executive health” programs, they typically relied on their executive patients to take a copy of the test results and recommendations for health maintenance or improvement back to their own personal physician.  Some have sent copies, with patient permission, to ensure the personal physician can follow up.  More recently, a few such hospitals are offering continuous coaching by specialized nurse coaches during the period between executive health visits or stays.  The extent to which the patients’ primary physicians know about these coaching contacts and coaches know about primary physician visits, or that all such visits and contacts are jointly coordinated or integrated is something that depends on the providers involved.

In most cases when proactive HM efforts aim at a particular and permanent behavior change by participants, such as quitting smoking, it might seem that continuity is not needed once the change is made.  But most lifestyle changes, particularly switching to a healthier diet, quitting smoking, or ending substance abuse are subject to frequent relapse or backsliding.  Only continuous monitoring will enable HM providers to determine when this happens, and to adjust their HM contacts accordingly.  Continuous monitoring is also the only way that providers can determine what works and does not, when they are managing the health of their own employees, as well as track and evaluate results they have agreed to deliver to employer clients.

Until and unless traditional providers are willing to take on the burden and risks of continuous follow up of HM participants, they are unlikely to be successful enough to be competitive sources or HM services.  As employers dealing with their own employees, they have great advantage in terms of continuity since employees typically work at the hospital’s facility, and can be followed at work.  Of course, HIPAA regulations limit the extent to which such follow-up is permitted, and participating employees or dependents must give their permission, but at least it can be conveniently arranged, in most cases.

When hospitals or other traditional providers are offering HM services to other employers, arranging cost-effective and competitively-priced follow-up will be part of the overall cost, as well as continuity challenge.  There is no barrier to using the same technologies as specialized HM suppliers have found effective, however, and once they have made the commitment, traditional providers should be able to overcome any history of discontinuity they have when embarking on HM programs.