Charlotte Carlson, MD, MPH Clinical Geriatrics Fellow University of California at San Francisco AAHCM Annual Meeting, May 14, 2014, Orlando, FL ©AAHCM

 Complex illness needs vs. usual care  Relevant features of complex illness care for frail and seriously ill adult populations  Limitations of disease-focused quality metrics when applied in frail and seriously ill adult populations ◦ Example: Patient-centered medical home ©AAHCM

Importance of personal goals Burden of treatment Functional status Time to treat ©AAHCM

Coordination and 24/7 Access Individualized Care Planning Continuous care Team-based

©AAHCM Komisar and Feder, 2007

Continuous Care: Patient-Centered Approach Patient to Primary Care Examination primary care Examination Hospital Diagnosis & decision on treatment PC/ Hospital Rehabilitation Primary Care Treatment Hospital Rehabilitation Community Care Patient focused Primary Care (6) Rehab ER Medicine Hospital Community care Traditional patient treated patient ill Lab Pharmacy Esther Project, 2010

Disease (i.e. DM) Process (i.e A1c <7) Outcome ( dec microvascular dz) ©AAHCM Health Status Patient preference & goals Time needed to treat Risk of adverse outcomes

45 yo DM2 only 89 yo DM2, AD, deaf, blind, HTN, CAD, CHF, HTN, OA,COPD, unreliable caregiver Courtesy of B. Leff, 2014

 Quality measures somehow need to acknowledge and incorporate additional dimensions ◦ Caregiving ◦ Psychosocial issues ◦ Disability ◦ Frailty ◦ Treatment Burden ◦ Others Comorbid Disease Comorbid Disease Comorbid Disease Index Disease Multimorbidity Patient Condition Courtesy of B. Leff, 2014

 Identify when complex illness needs are present  Move away from disease-focused metrics  Develop individualized quality markers that capture concordance with individual goals  Acknowledge and incorporate additional dimensions ◦ Caregiving ◦ Disability ◦ Frailty ◦ Treatment burden ©AAHCM