1. 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

2. 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.

3. 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.

4. 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.

5. 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:

6. 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.

7. Care Coordination “Don’t doctors talk to each other?”
Kamil Swiatek
Oakville, Ont.

8. 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 41 12 59 36 19
Information about changes to patient’s drugs or care plan 30 24 47 5 44 22 16
Information that is timely and available when needed 11 4 1 15 8 27 18
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

9. After Hospital Discharge, Primary Care Doctor Receives Needed Information to Manage the Patient Within 48 Hours
Percent
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

10. Patients experience and clinicians operate in “silos” of care.
Who is responsible for connecting the silos????

11. 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.

12. 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.

13. Why make care coordination a priority?
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

14. 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.
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.

15. How to improve care coordination: findings from study of literature and best practices1.
Assume accountability 2.
Provide patient support 3.
Build relationships & agreements 4.
Develop connectivity

17. 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.

18. 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.

19. 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.

20. 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, e-referral, and/or agreements.

21. What would one see in a practice that coordinates care well?1.
Assume accountability 2.
Provide patient support 3.
Build relationships & agreements 4.
Develop connectivity

22. Works best when the care manager:
Care management
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.

23. Relationship between care coordination & care management activities in primary care
Logistical
Clinical Monitoring
Care Coordination
Clinical Follow-up Care
Medication management
Self-management Support
©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011
Care
Management
Functions

24. 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.

25. How to implement care management
which populations are to be managed.
Decide
clinical priorities for care management—for example: monitoring, medication management
Determine
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 25

26. 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, , 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:

27. 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.

28. 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.