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Back To The Future? Redesigning Healthcare To Meet The Needs Of Our Sickest Patients

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When I was a physician in Boston, I had the pleasure of taking care of Elizabeth Owens.* Ms. Owens was well known to most of the other physicians at our hospital because she was sassy and spared no opportunity to use her sharp tongue.

Ms. Owens’s hospitalizations were varied in their causes: One time it was hyperglycemia and congestive heart failure. Another time it was cellulitis that progressed into a non-healing ulcer. And yet another time, her dialysis fistula had become obstructed.

Little we did for Ms. Owens seemed to change her course. She was lonely and frustrated. She could never make her outpatient appointments because she had no one to bring her to them. She had a fundamentally poor understanding of her diseases and her care. Anyone who has spent time in the trenches of care delivery knows that patients like Ms. Owens populate our nation’s healthcare system—patients whose needs are part medical, part social.

Ms. Owens’ experience points to a troubling reality I encountered during medical training and practice. The U.S. healthcare system does not consistently meet the unique needs of some patients who need it most: frail elders. A graphic from a 2012 Institute of Medicine report paints a striking picture:

Source: Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

Many of these data are for the average Medicare patient. It’s almost hard to imagine what they might be for the sickest of the sick.

This graphic underscores the root of the challenge in caring for frail elders. Due to complex medical conditions, these individuals are often cared for by various individuals (family members, nurses, physicians, home health aides) across various settings (home, outpatient, hospital). Despite best intentions—and best practices and clinicians—information is sometimes lost in translation as patients cycle through various sites of care. We need to find ways to improve the care for most vulnerable patients—and we look to the past, where continuity was a hallmark of medical care, for inspiration. In an article published earlier this month in JAMA with my colleagues Brian Powers (of Harvard and also a CareMore Innovation Fellow), and Arnold Milstein (of the Stanford University School of Medicine)—Delivery Models for High-Risk Older Patients: Back to the Future?—we explore new approaches to caring for these patients. We focus on programs where the same physician sees patients across different sites of care.

One of these models is the Comprehensive Care Physician (CCP) program led by David Meltzer (a hospitalist and economist) at the University of Chicago. Under the CCP program, high-risk elderly patients seen at the University of Chicago Medicine are paired with a hospitalist who also assumes the role of primary care provider. When these patients are discharged from the hospital, they are seen by the same physician for outpatient follow-up. The same physician can also care for them during subsequent hospitalizations or even visit them and help guide care during adult emergency department visits. The CCP program is currently being evaluated under a randomized controlled trial and results are expected later this year.

The article also describes the CareMore model of care (where I lead clinical care delivery) in which extensivist physicians follow high-risk Medicare and Medicaid patients for an entire episode of acute illness from the hospital to skilled nursing facilities to outpatient follow up. Compared to national Medicare data CareMore has consistently operated with shorter lengths of stay, fewer hospital admissions and lower readmission rates.

We believe these fundamental changes in the organization and delivery of healthcare will have profound effects on the quality and efficiency of care for frail elders.

Under the models of care described above, Ms. Owens might have had regular access to the same physician who managed all aspects of her care. She might never have been admitted for heart failure or high blood sugar because close follow-up would enable medication adjustments before her condition worsened. She might never have lost her dialysis access because her clinicians would ensure regular maintenance and cleaning were administered. She might not have suffered a non-healing ulcer because her outpatient care providers would have aggressively managed it so that it did not become bad enough to require hospitalization.

And in the rare instance where she did need hospitalization, she would be treated by a physician who would not just see and manage her in the hospital, but also during her rehabilitation facility stay and subsequently in clinic to follow up, helping to ensure her care was effectively coordinated.

Ultimately, what is most exciting about the CCP and similar programs is the willingness to redesign traditional roles and models of care. Too often we are playing catch-up, patching inadequacies in the current system with tools such as post-discharge planning, outpatient care managers and various alerts and notifications. The incremental approach of these programs may explain why many fail to demonstrably improve outcomes.

I am hopeful that Medicare’s shift toward value-based, alternative payment models will accelerate experimentation with new approaches and remove the barriers to redesigning care, ultimately benefiting those that matter most–patients, like Ms. Owens.

*name changed to protect patient privacy