chronic disease management

EPIC PC I-ACT Model of Healthcare for Complex, Chronic Disease Management

Today, the success of a healthcare provider is measured according to his/ her ability to consistently deliver superior quality, value-based care, and improve patient outcomes in the long term. This is a huge shift from the traditional setup when success was measured as per the number of patients treated by a particular physician or an institution. For the current setup to function effectively there has to be a cross-functional team in place to offer round the clock health services. This means that it will take more than one physician to provide quality, timely, and holistic care for a single patient.

A Patient Is More than Their Illness

At EPIC Primary Care, we recognized the need for a holistic treatment of patients early on. Thus, we adopted the ACT model of patient care – Advanced Care Team. A typical ACT consists of a clinician, dietician, counselor, exercise physiologist, pathologist, and/or diagnostic technicians, pharmacist, nurse, and assistants for any or all of the above, depending on the individual case. This allows us to go beyond the visible symptoms of a patient, delve deep into the patient’s physique and psyche, and provide all-round, effective care to ensure their optimal wellness for the long term.

The ACT model of healthcare delivery is particularly important for people with severe chronic diseases like:

  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure
  • Coronary heart disease
  • Hypertension
  • Diabetes
  • Dementia – Alzheimer’s, etc
  • Mental health issues – suicidal tendencies, depression, severe anxiety, etc
  • Parkinson’s disease
  • Cancer
  • Obesity
  • Epilepsy
  • Stroke
  • Alcohol related health issues (like liver Cirrhosis)

All of these health conditions require long term (often lifelong) medication, regular exercises, mental health counseling, diet control, and other therapies.

The Need for the ACT Model

Before we even discuss the ACT model in detail, one may wonder why such a holistic approach is required in the first place. This is because, apart from medication, many other factors may require correction for the patient outcome to improve. Let’s review a few examples:

  • An elderly patient with heart failure lives alone; she is willing to take her medications on time, but is unable to visit the pharmacy to pick up the medicines. What can be done?
  • An obese person may be depressed or anxious, or have other mental health problems, and mere dieting without counseling may simply not work.
  • A patient with depression who had a fall may be completely unmotivated to go for his physiotherapy sessions and may end up damaging his joints even further.
  • A patient with thyroid dysfunction may also have high cholesterol, and/or diabetes, and may have a rocky family life.
  • A diabetic patient may not be aware of all the foods she needs to avoid, or how much physical activity she requires to control her blood sugar levels.

So, you can see that non-clinical factors, like socio-economic, behavioral, and mental health issues can impact patient outcomes to a great extent – and so, it is crucial, that a healthcare provider takes all these factors into consideration to provide value-based care.

The ACT model at EPIC helps to identify as well as manage high risk, high cost, and highly complex patients, and take care of all issues – external and internal, that hamper a successful patient outcome. The entire team sits together, and under the guidance of the physician, who leads the team, creates a customized treatment and care plan that seeks to address the various issues the patient is facing.

Here are some ways in which the ACT model of healthcare at EPIC Primary Care benefits patients:

  • The holistic requirements of the patient are acknowledged as opposed to mere treatment of visible symptoms
  • The patient is provided resources, guidance and counseling so that they are better educated about their condition, treatment options, lifestyle changes and so on. Patients are encouraged to take charge of their health
  • Patients with chronic diseases need very frequent monitoring of their vitals – blood sugar, blood pressure, cholesterol levels, lung function, liver function, and so on. By providing the convenience of diagnostic tests at our Care Centers, we make it easy for patients to get themselves tested when they come in for their regular consultation with our EPIC physicians. Significant shift in the readings may be indicative of a need to adjust medicine dosages, or change the medication itself.
  • Our in-house dietician works closely with them to understand their current habits, their goals, their preferences and so on, and guides them regarding healthy choices. She creates meal plans with portion sizes, quick, healthy and tasty meal recipes, and more.
  • Our in-house exercise physiologist creates custom workout plans for patients based on their specific health issues and requirements. They guide the patients on continuing the exercises at home and to monitor progress.
  • The EPIC Pharmacy is integrated with the Care center. This ensures that the pharmacist can confer as and when required with the doctor regarding dosages, frequency, and so on, and that there are no prescription errors. Additionally, medicines can be picked up by patients after their consultation at the center, or have them delivered home.
  • EPIC Primary Care provides transportation facilities to seniors and other patients who are unable to travel to the center for any reason
  • As a tech-enabled practice, everything is available online, and every member of the care team can access information about the patient as they need. This allows the team members to take informed decisions in emergencies, without having to wait for instructions. Patients are also given apps that help them track their medicine schedule; monitor their exercise goals; and stick to their diet, etc.
  • With a dedicated team working for every patient, there is greater collaboration and better communication amongst the team members. This helps to significantly improve the quality of care delivered, and enhance the overall health of the patient –not merely treat the illness the patient is faced with.
  • The patient receives personalized care and has a caring, trusting atmosphere. The care team builds strong relationships with patients, performing tasks like visiting the patient at home to ensure they take their medications. They even go to ensure that the patient is following up with dietary and/or exercise recommendations.

At EPIC Primary Care, we treat patients like our family –we go the extra mile to help our patients achieve their health goals and enjoy long term optimal wellness.

Do you or a family member have a chronic health condition that requires constant monitoring and frequent checkups? Are you looking for superior quality health care? If yes, schedule an appointment with an EPIC physician today.

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