Meeting the Needs of Patients
with Complex Problems
Ed Wagner, MD, MPH, MACP
MacColl 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 diseasespecific guidelines.
 Added care complexity
<multiple guidelines, multiple registries, difficult comorbidities such as psychiatric disorders and substance
abuse
 Polypharmacy
 Multiple physicians and a poor care
coordination culture and mechanisms.
Percent of patients reporting problems in care
by 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 care
 Self-management support
 Care 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?”
Kamil Swiatek
Oakville, Ont.
7
Primary Care Doctors’ Receipt of Information from Specialists
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.
8
After Hospital Discharge, Primary Care
Doctor Receives Needed Information to
Manage the Patient Within 48 Hours
Percent
100
80
67
56
60
45
42
40
40
36
21
21
20
15
14
CAN
NOR
10
0
GER
NZ
US
NET
SWIZ
AUS
UK
SWE
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
FRA
9
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.”
.
McDonald, et al. Closing the Quality Gap, Vol. 7. AHRQ, 2007.
11
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?
Happier
patients
Patients and families hate it that we can’t make this work.
Fewer
problems
Poor hand-offs lead to delays, lapses in care, adverse drug
effects, and other problems that may be dangerous to health.
Enormous waste is associated with duplicate testing,
unnecessary referrals, unwanted specialist-to-specialist
Less waste referrals, and failed transitions from hospitals, EDs, & nursing
homes.
Happier
physicians Clinical practice will be more rewarding.
& staff
13
The goals of care coordination:
high quality referrals and transitions
Safe
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.
Patientcentered
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
1.
2.
Assume
accountability Provide
patient
support
3.
4.
Build
relationships Develop
& agreements connectivity
15
16
Steps for improving care coordination
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.
17
Steps for improving care coordination (cont.)
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.
18
Steps for improving care coordination (cont.)
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.
19
Steps for improving care coordination (cont.)
4. Develop connectivity
• Evidence indicates that standardized info. and
interactive communication improves outcomes.
• Develop ways to enable standardized
information: and interaction: shared EHR, ereferral, and/or agreements.
20
What would one see in a practice that
coordinates care well?
1.
2.
Assume
accountability Provide
patient
support
3.
4.
Build
relationships Develop
& agreements connectivity
21
Care management
Providing follow up, clinical management, and selfmanagement support to patients outside of clinic visits.
Works best when the
care manager:
Services and intensity
of services vary with
the severity of the
illness.
Provided by a staff
person for lower risk • Is an integral member
patients and by a
of the practice team
nurse or other health • Can influence drugs
professional for high- • Has access to clinical
risk patients.
support.
22
Relationship between care coordination &
care management activities in primary care
Care Management
Medication management
Self-management Support
Logistical Clinical Monitoring
Care
Management
Functions
Clinical Follow-up Care
Logistical Clinical Monitoring
Care Coordination
Logistical
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
23
Will care manager interventions be effective for multiproblem 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
Decide
Determine
• which populations are to be managed.
• clinical priorities for care management—for example:
monitoring, medication management
Develop & use • a systematic case identification strategy.
Identify & train • care managers.
Enable
• the care manager to be a member of the practice team.
Create
• a support structure for the manager.
25
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.