Meeting the Needs of Patients with Complex Problems

Ed Wagner, MD, MPH, MACPMacColl Center for Health Care Innovation

Group Health Research Institute

January 2013

The challenges of caring for the patient with multiple chronic conditions

Limited evidence base – < complex, older patients excluded from trials, hints of poorer outcomes when treated according to disease-specific guidelines.

Added care complexity <multiple guidelines, multiple registries, difficult co-morbidities such as psychiatric disorders and substance abuse

Polypharmacy

Multiple physicians and a poor care coordination culture and mechanisms.

Percent of patients reporting problems in careby number of doctors seen

Base: Adults with any chronic condition

Percent reported any errors in past 2 years*

Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

What do Patients with Chronic Illness Need to Optimize Outcomes

Drug therapy and medication management that gets them safely to therapeutic goals.

Effective self-management support so that they can manage their illness competently.

Preventive interventions at recommended times.

Evidence-based monitoring and self-monitoring to detect exacerbations and complications early.

Follow-up tailored to severity, and more intensive management for those at high risk.

Timely, well-coordinated services from medical specialists and other community resources.

But, the multi-problem problem patient likely increases the need for:

Full implementation of the patient-centered medical home with “whole-person” knowledge of the patient and clearer accountability for the totality of care.

Primary care clinicians able to integrate input from multiple specialties/agencies into a coherent, patient-centered treatment plan.

Clinical care management services integrated with medical homes.

More assertive and effective care coordination.

Access to mental health and substance abuse services.

Greater sharing (interactive communication*) of care planning and care management between primary and specialty care.

* Foy et al. Ann Int Med 2010; 152:247-258

Successful practices really understand the critical functions that lead to high quality

Population management Planned, proactive careSelf-management supportCare management/Follow-up/Care Coordination

TO “really understand” a function means hard wiring it into your care system.

Care Coordination“Don’t doctors talk to each other?”

7

Kamil SwiatekOakville, Ont.

Primary Care Doctors’ Receipt of Information from Specialists

8

Percent said after their patient visits a specialist they always receive:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Report with all relevant health information

32 26 51 13 13 41 26 12 59 36 19

Information about changes to patient’s drugs or care plan

30 24 47 12 5 44 22 13 44 41 16

Information that is timely and available when needed

13 11 26 4 1 15 4 8 27 18 11

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

After Hospital Discharge, Primary Care Doctor Receives Needed Information to Manage the Patient Within 48 Hours

9

GER NZ US NET SWIZ AUS UK SWE CAN NOR FRA0

20

40

60

80

100

67

56

45 42 4036

21 2115 14

10

Percent

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Patients experience and clinicians operate in “silos” of care.

Who is responsible for connecting the silos????

Care coordination

Care coordination is “the deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”

.

11McDonald, et al. Closing the Quality Gap, Vol. 7. AHRQ, 2007.

Successful practices monitor and support their patients when they leave the practice.

Many patients need monitoring beyond what can be done in office visits.

Many patients need services beyond what can be provided in the clinic.

A few patients need clinical management beyond what can be done in office visits.

Why make care coordination a priority?

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Patients and families hate it that we can’t make this work.Happier patients

Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other problems that may be dangerous to health.

Fewer problems

Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes.

Less waste

Clinical practice will be more rewarding.Happier

physicians & staff

The goals of care coordination:high quality referrals and transitionsSafe Planned and managed to prevent harm to patients from

medical or administrative errors.

Effective Based on scientific knowledge, and executed well to maximize their benefit.

Timely Patients receive needed transitions and consultative services without unnecessary delays.

Patient-centered

Responsive to patient and family needs and preferences. Supports important provider-patient relationships.

Efficient Limited to necessary referrals, and avoids duplication of services.

Equitable The availability and quality of transitions and referrals should not vary by the personal characteristics of patients.

How to improve care coordination: findings from study of literature and best practices

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1.

Assume accountability

2.

Provide patient support

3.

Build relationships & agreements

4.

Develop connectivity

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Steps for improving care coordination

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1. Assume accountability

• Initiate conversations with key consultants, EDs, hospitals, and community service agencies.

• Set up an infrastructure to track and support patients going outside the PCMH for care—referral coordinator and tracking system, care manager for transitions.

Steps for improving care coordination (cont.)

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2. Provide patient support

• Help patients identify sources of service—especially community resources.

• Help patients make appointments.

• Track referrals & help resolve problems.

• Ensure transfer of information.

Steps for improving care coordination (cont.)

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3. Build relationships & agreements• Practice leaders initiate conversations with key

partners in care to share their expectations.

• Specialists have legitimate concerns about inappropriate or unclear reasons for referral, unclear expectations.

• Agreements are sometimes put in writing or incorporated into e-referral systems.

Steps for improving care coordination (cont.)

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4. Develop connectivity

• Evidence indicates that standardized info. and interactive communication improves outcomes.

• Develop ways to enable standardized information: and interaction: shared EHR, e-referral, and/or agreements.

What would one see in a practice that coordinates care well?

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1.

Assume accountability

2.

Provide patient support

3.

Build relationships & agreements

4.

Develop connectivity

Care management

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Providing follow up, clinical management, and self-management support to patients outside of clinic

visits.

Services and intensity of services vary with the severity of the

illness.

Provided by a staff person for lower risk

patients and by a nurse or other health professional for high-

risk patients.

Works best when the care manager:

• Is an integral member of the practice team

• Can influence drugs• Has access to clinical

support.

Relationship between care coordination & care management activities in primary care

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Care Management

Logistical

Logistical

Logistical Clinical Monitoring

Care Coordination

Clinical Follow-up Care

Medication managementSelf-management Support

©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011

Clinical Monitoring

Care Management

Functions

Will care manager interventions be effective for multi-problem patients?

Care manager interventions improve outcomes in diabetes, depression, bipolar disorder, CHF, etc.

TEAMcare study and Geisinger evaluation suggest effectiveness across conditions.

Evidence much less convincing for multi-morbid, geriatric patients. Cost savings elusive.

Integration of the care manager with primary care appears critical.

How to implement care management• which populations are to be managed.Decide

• clinical priorities for care management—for example: monitoring, medication managementDetermine

• a systematic case identification strategy.Develop & use

• care managers.Identify & train

• the care manager to be a member of the practice team.Enable

• a support structure for the manager.Create

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Will greater sharing of care between primary and specialty care improve care for complex patients?

Recent meta-analysis* of interventions to increase collaboration between primary and specialist physicians found consistently positive effects on patient outcomes in mental illness and diabetes.<Effect sizes lager than those seen in drug trials (e.g., average

HbA1c reduction of 1.4%).

Effective interventions include:< interactive communication—telephone, E-mail, videoconference< quality of information—structured information, pathways to improve information quality

It is not clear how this might work with the multi-problem patient.

* Foy et al. Ann Int Med 2010; 152:247-258

New roles for Medical Specialists

Population perspective – increase the reach of specialist expertise

Policy perspective -- while reducing specialist visits/evaluations

By supporting medical homes

Teaching/supporting primary care providers

Virtual consultations

Co-location arrangements and telehealth

Supporting care managers

Limiting practice to patients that primary care is ill-equipped to manage

Consult on multi-morbid patients, but don’t provide primary care.

Complex Patients and the Future

Complex patients will increase in prevalence.Their management will become increasingly

complex.They will account for a greater and greater

percentage of the healthcare dollar, especially if primary care is unable to play a significant role in their care.

Governments have been looking for quick fixes that may undermine medical practice.