The Challenge Of Caring for Patients with Complex Needs

We know that the greatest challenge facing our health system is to provide effective care for patients with complex and chronic conditions.

The US Agency for Healthcare Research and Quality addresses this question in a recent White Paper, “Cooordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions”

In this months Annals of Family Medicine, the White Paper author Eugene Rich summaries the policies and strategies developed to help typical, smaller primary care practices transform into effective medical homes that appropriately serve patients with complex needs. All the programs that they studied allow patients with complex needs to maintain existing relationships with their primary care clinicians while giving small practices the resources to overcome barriers to providing excellent care to these patients. A further ‘brief paper’ Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs also accompanies the AHRQ White Paper. The summary below draws from the Annals article and the Brief paper.

The patient-centered medical home (PCMH) is a model for strengthening primary care through the reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care that is continuously improved through a systems-based approach to quality and safety. Agency for Healthcare Research and Quality (AHRQ). What is the PCMH? AHRQ’s definition of the medical home?

Recent studies have confirmed that the care provided by a patient-centred medical home reduces morbidity and costs.

The programs that were studied for the White Paper used a number of key approaches to support primary care practices.

Focusing on the most costly patients.

Placing case managers/care coordinators in primary care practices.

Case managers/care coordinators are typically nurses, social workers, or other professionals who work as a team with the primary care clinician. Case managers/care coordinators extend the reach and capacity of primary care clinicians to provide more proactive care by making home visits, providing 24-hour on-call advice, and helping patients find and secure community-based services.

Allowing flexibility in matching staff to the needs of each practice.

These staff include case managers/care coordinators, as well as specialists in geriatrics, nutrition, mental health, and assistive technology. In many programs, staff rotate among several primary care practices, but if a practice has enough patients with complex needs, support staff can be assigned to just one.

Helping primary care clinicians manage patients with complex care needs alongside their regular patients.

Most of the programs help reorganize workflow and systems; identify and proactively track complex or high-risk patients via registries; conduct in-home assessments; staff 24/7 telephone lines to complement the practice’s after-hours coverage; set up electronic health records, Web-based IT registries, and referral tracking systems;

Quality Improvement Activities and Learning Opportunities

All of the programs emphasize quality improvement, and monitor utilization and quality indicators to identify areas for improvement;
Team-based quality improvement through peer-to-peer learning and in-person meetings is another common approach

Paying additional fees to compensate primary care practices for time required to care for people with complex care needs.

Most of the innovative programs augment current payment to primary care practices with a monthly amount per patient, sometimes adjusted to reflect disease or condition complexity, which enables the practices to spend time on comprehensive assessment and care coordination.

What are the Next Steps?

Patients with complex health care needs represent the greatest challenge to transforming small primary care practices into high-functioning medical homes. These patients also present a great opportunity for medical homes to dramatically improve outcomes, such as lower costs, higher-quality care, and better care experiences for patients and clinicians. To achieve these aims, small practices will require enhanced support and resources—beyond those needed to meet current medical home standards—to deliver optimal care to patients with complex care needs. The 2 most crucial supports appear to be additional practice reimbursement for time spent coordinating care and integration of care coordinators with primary care teams.
Annals of Family Medicine

We have a tremendous opportunity in Australia to lead the world in the management of patients with complex needs by ensuring that our health system re-focuses on primary care, building on the resources, skills and relationships that exist in General Practice.

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