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.

These features are comprehensiveness, patient-centeredness, and evening and weekend office hours, the University of California, Davis researchers reported in the latest Annals Of Family Medicine (Jan.Feb 2012)

cf http://www.annfammed.org/content/10/1/34.full

The evidence continues to show that what makes a difference is “longitudinal relationships over time with comprehensive care and excellent access.”

This can be used as the key component of a GP Management Plan and Team Care Arrangement. It can act as a communication tool between all providers involved in a patient’s care – are they all ‘on the same page’?.

It can also contain information for the patient about their conditions. This can be provided by a range of team members to assist in self management.

‘A4 Document Folders’ with plastic sleeves have been used by many practices.

The Patient Held Record may contain

• the patients current problems
• medical history
• current medication list
• key goals and targets, and progress towards them
• recent results (bloods, Xrays, ECGs, spirometer readings)
• specialist letters
• a care calendar
• referral letters to specialists, Xray and pathology
• information about their condition (handouts)

Doctors Grand Plaza have posted their story ‘The Blue Folder‘ to the APCC 1001 stories web site. This includes an example of “the care calendar” they have developed.

Your comments and suggestions are welcome.

Are there any pages or templates you have found useful to include in a Patient Held Medical Record?

“Patient–Physician Connectedness and Quality of Primary Care.”is a study which aimed to determine whether quality of care is better when patients and doctors are connected than when these connections are not present.

155 590 adults who had at least 1 visit to a doctor in a network of primary care practices were included in the study.

The researchers used data from clinical systems to identify patients who received most of their primary care from a specific doctor or from different doctors in a specific practice. Other patients were considered not connected to either a physician or a practice; usually, these patients were transitioning out of the health care network. The researchers then looked for a relationship between “connectedness” and several measures of quality of care: cancer screening in eligible patients, diabetes monitoring and control in patients with diabetes, and cholesterol monitoring and control in patients with diabetes and heart disease.

About 60% of patients were connected to a doctor, about 34% were connected to a practice, and about 6% were not connected to a doctor or practice. Large differences in insurance status and racial and ethnic groups were found among patients were who were unconnected or connected to a physician or practice; unconnected patients were more likely to be uninsured and of an ethnic and racial minority group. Patients who were connected to a physician were most likely to receive recommended care, whereas patients connected to a practice were less likely to receive recommended care. The researchers did not assess outcomes in unconnected patients.

This study was limited in that it included only 1 primary care network and looked at only a few measures of quality of care.

The study concluded that patients who see a specific doctor are more likely to receive recommended care than patients who are not connected to a specific doctor.

The study that we really need next is one that compares patients connected to a particular practice, to patients not connected with a particular practice.

“Patient–Physician Connectedness and Quality of Primary Care.” in the 3 March 2009 issue of Annals of Internal Medicine (volume 150, pages 325–335). S.J. Atlas, R.W. Grant, T.G. Ferris, Y. Chang, and M.J. Barry.

The recent TRANSLATE trial tested the effectiveness of a ‘multi-component organisational intervention’ for diabetes patients in primary care practices.

All practices in the study were provided with a report of their baseline measures and were instructed to target the same values.

In addition, intervention practices were supported by a clinical information system providing patient-specific clinical decision support and promoting proactive engagement of patients. Specific components were directed to the patient, the physician, and the clinic staff.

The particular components of the intervention correlate with many of the change ideas used in our chronic disease management collaboratives. Happily, they produce the acronym TRANSLATE.

• Target high risk - identify and begin with patients at highest risk.
• Registry- Create a registry for data collection, reporting, and support.
• Administration – Set up administration to oversees changes in roles and
  responsibilities and enhance continuity during staff turnover.

• Notify and remind – Notify patients of targets and appointments. Remind providers at time of visit with patient-specific alerts.
• Site coordinator- Identify a site coordinator to facilitate the clinic operations.
• Local physician champion - Identify a lead provider to work with the site coordinator and facilitate the intervention with colleagues.
• Audit and feedback Audit and review monthly. Provide feedback to improve progress.
• Track Track process measures, outcomes, and operational activity.
• Education Educate and update all staff in diabetes management techniques.

The results were impressive. All pratices (control and intervention) significantly increased process measures – but only intervention practices significantly improved clinical outcomes, and this was achieved to high significance in a composite blood pressure, LDL and HbA1c measure.

The conclusion –

‘this combination of components provides a proven strategy for initiating improvement in clinical diabetes care for many primary care practices.’

How about another S for Sharing the stories.
TRANSLATES may have produced even better outcomes than TRANSLATE.

Or a C for Collaboration. Acronym anyone? Leave your suggestion in the comments below.

Much of the work we do as clinicians involves behaviour change.

In a recent Health Report on Radio National, Norman Swan interviewed the American researcher Associate Professor Kent Harber. Prof Harber has done research on the affect the amount of social support and our available resources affect our perception on the challenges we face. Hills literally look steeper when we’re feeling down or isolated.

I wonder if this is helpful for us. This is why, for example, encouraging weight loss requires more than just telling our patients to ‘eat less – do more’. We need to deal with their psychology – the social supports they have available and their emotions about the challenges they face.

This helps to explain why having a friend participate in a healthy lifestyle program makes such a difference. Certainly, I know that I work much harder in a ‘spin’ class when my wife takes me along with her than I ever would on an exercise bike at home.

Here is a snippet from their interview :

Kent Harber: There’s a researcher at University of Virginia named Dennis Proffitt who is a vision researcher not a social psychologist and his interest is how people perceive physical challenges like how steep a hill is because you’re going to hike it. And what he finds is that the physical state or the physical burden of the person shapes and affects their perception of how steep that hill is.

Norman Swan: Is it a physical or psychological burden?

Kent Harber: Well his interest is in physical so if a person is in very good shape they see a hill as less steep than if they are not in so good shape. Older people see the hill as steeper than younger people, someone wearing a heavy back pack sees a hill steeper than someone not wearing a heaving back pack. What our interest was OK if physical burdens effect how we see hills what about psychological burdens or the alleviation of them. So what we did is we had our participants standing at the base and we just got people who happened to be in the vicinity who are either all alone or with a friend and they estimated how steep was the hill. They gave us a verbal estimate – how steep is it in degrees, they gave us what’s called a visual estimate, we had a device that looks like a pizza pan that you can open up or shut and then there’s a third estimate which is called a haptic, where you put your hand at the angle you think the slope is, that’s how your body sees the hill. Proffitt always finds that people’s haptic measures are always accurate, your foot knows where to place itself on the hill but the visual estimates are those that tend to be exaggerated. What we found is that our subjects who were with their friend saw the hill as less steep than those who were not with a friend and the longer they knew their friend the less steep the hill became.

In the second stage we thought, well, you’ve got people here who show up with friends, people -

Norman Swan: It could be an accident of fate that they’ve turned up by themselves.

Kent Harber: Or maybe socially isolated people…………

Norman Swan: Don’t even go to the hill.

Kent Harber: Exactly, so the participants either thought about, as in the pain study, they thought about a very good person, a neutral person or a negative person, they went to the hill. People who thought about a positive person saw the hill as less steep, the closer they felt towards the person they thought about, the less steep the hill became; same hill, different social context.

Like a new golfer, general practice is a frequent recipient of advice.

Towers of guidelines rise threateningly above our desks, taunting us in their unopened plastic sheaths. Evidence floods our mailboxes like spam does our email boxes. Your patient’s cholesterol should be this, their BP should be less than such and such, everyone should take this, no-one should do that.

Common to the advice we receive is that no one offering it knows how to achieve the suggested outcomes in practice. We are told to hit the ball into the hole, but we are not told how to achieve that.

Barbara Starfield (Professor of Medicine at John Hopkins School of Public Health) has studied the effectiveness of health care systems around the world. She tells us that chronic illness is not improved by more specialists, better diagnostic tools, or new treatments. Chronic illness is improved by the better delivery of primary care.

The National Primary Care Collaborative (NPCC) program is working to bridge the gap between what the evidence tells us and what is achieved in practice. The program assists practices to improve their systems through a process of small, incremental changes, and measuring the result of each action to ensure that the change is an improvement.

487 practices Australia wide have participated in the fist three waves of the program, with another 68 currently involved in local collaboratives. In total, 29 practices from this division will have been trained in the process.They are sharing their stories and the steps that they take to improve their systems.

So what have we learnt from our peers about the best way to ‘hit the ball into the hole’ with regard to our diabetic patients? Every practice is unique, of course, but successful practices have many of the following characteristics

They have allocated time to examine the systems and process that are used in their practice.

They have an accurate diabetes register and know their patient population. They have systems in place to measure the outcomes their patients are achieving. They know the percentage of their practices who are reaching targets in HbA1C, blood pressure, cholesterol, etc. and they can identify those who are not to target.

They have decided as a whole practice they will be proactive and systematic in the management of their diabetic patients and have engaged their practice team to assist in this process.

Most use Practice Nurses as Chronic Disease Managers, as it seems RNs often have better skills in being systematic then doctors. In addition, some practices have appointed practice management staff to act as Administrative Disease Register Managers, to manage recalls and reminders, and to assist in identifying patients who might benefit from more intensive interventions.

They provide integrated care.

Often diabetic educators, dieticians or exercise physiologists perform clinics in the practice. Care delivered outside the practice will be co-ordinated so that communication is comprehensive and timely.

Patient self management is fostered.

Patients who understand their own condition and the targets they should achieve are significantly more likely to have better control of their diabetes. Some practices organise supermarket visits, and others group educational evenings.

They have developed comprehensive cycles of care for their diabetic patients.

The practice system ensures that each patient receives the appropriate care from the appropriate team member at the appropriate time. They have adopted a continuous quality improvement model, and therefore continue to make small changes and measure the outcomes. They utilise EPC and practice nurse item numbers optimally to improve their practice finances, ensuring the sustainability of their processes.

If you keep doing what you’re doing, you keep getting what you’re getting.

Practices that have developed skills in the collaborative method often report that it is exciting to adopt a more proactive approach to diabetic management. The team approach has enabled them to improve the patient’s heath outcomes and the practice incomes, while making work easier for the doctors. That’s got to be better than par.