Last month I attended the Complexity of Care in Primary Care Practices Conference convened by Western Washington University in Bellingham, a town 90 miles from Seattle. The MacColl Center has through the years enjoyed strong relationships with Bellingham provider teams, as much due to their innovative practices as our close physical proximity. I’d been asked to give a lecture, and my topic was “Improving Health Services for Patients that Require Complex Care”. Driving that morning towards our northern neighbors for the conference, I thought about caring for complex patients. Goals for the workshop included developing strategies to better care for those patients in our state with complex health care needs, and identifying community linkages in support of those efforts.
Who are complex patients?
In addition to multiple chronic conditions, they are often those with co-existing frailty, mental/behavioral health needs, substance abuse, and weak or non-existent social support systems. They usually require more intensive medical services, and the work of caring for these patients must be coordinated across multiple providers while integrated with a range of other supports for maintaining health and functioning. They are the 10% of patients who consume 80-90% of health care resources.
Recent health system transformation has focused on the patient-centered medical home (PCMH), with emphasis increasingly on complex patients. However, published PCMH outcomes thus far have shown mixed results. I don’t believe these outcomes indicate that the PCMH isn’t working, but I believe it points to the need for a fundamental shift in perspective. Most evaluations to date have included all patients, not just those who are likely to benefit the most from medical home redesign: the complex chronically ill. We need to widen our evaluation lens to focus on the medical neighborhood – not just the home. A medical neighborhood is bigger than the transformed primary care practice – it is the PCMH aligned with health systems and specialists, all delivering coordinated, managed care together.
Looking beyond the medical home
Solutions to problems around patients with complex health care needs are going to have to be local: a medical home must be supported by its surroundings. It is challenging for a home to be solid and safe if it’s in a neighborhood without streetlights to show the way at night, and the traffic signals are broken. Transformation of primary care through the medical home will take more than developing a sound approach to changing primary care teams. Primary care teams can’t do this work alone. Transformation requires a larger vision and will require leadership within each local medical community.
CARING FOR COMPLEX PATIENTS
- Rich E, Lipson D, Libersky J, Parchman M. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0010-EF.Rockville, MD: Agency for Healthcare Research and Quality. January 2012. [Link]
- “Practical Approaches to Complex Patients: Learning from Exemplar Ambulatory Practices”. Western Washington University. Complexity of Care in Primary Care Practices Conference. Bellingham, WA. March 24, 2014. [Link]
THE MEDICAL NEIGHBORHOOD
- Fisher, E. Building a Medical Neighborhood for the Medical Home. N Engl J Med. 2008 September 18; 359(12): 1202–1205. doi:10.1056/NEJMp0806233. [Link]
- Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Group Health’s MacColl Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011. [Link]
- Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014 Mar-Apr;12(2):166-71. doi: 10.1370/afm.1616. [Link]
MEDICAL HOME EVALUATIONS
- Health Aff (Millwood). 2010 May;29(5):835-43. doi: 10.1377/hlthaff.2010.0158. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Reid RJ1, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. [Link]
- Am J Manag Care. 2014 Jan;20(1):26-33. Patient-centered medical home transformation with payment reform: patient experience outcomes. Heyworth L1, Bitton A, Lipsitz SR, Schilling T, Schiff GD, Bates DW, Simon SR. [Link]
- JAMA. 2014 Feb 26;311(8):815-25. doi: 10.1001/jama.2014.353. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. Friedberg , Schneider, Rosenthal, Volpp, Werner. [Link]