Care Delivery: Building integrated care for patients with many co-morbidities
The term integrated care can sometimes feel like an over-used buzzword. So it can help to think about what it means for the very patients who are most often failed by existing fragmented systems of care. For Jonathan Darer that means those with complex co-morbidities and how they are treated across the medical system from acute to their homes. Here we to talk to Dr.Darer, Medical Director, Siemens Healthineers and former chief innovation officer at Geisinger to explore why and what integrated care for such patients should look like and how to best deliver it. Few healthcare systems in the world are yet capable of delivering a continuity of care experience that is needed for these complex patients.
He says such patients see a slew of different specialists – each writing orders for medications, tests and procedures and each giving patients and their families a different set of care instructions – but only for the condition that they treat. As a result, many chronically comorbid patients receive confusing or conflicting information. These sick and sometimes frail patients and their families are hurried from pillar to post – trying to sort out how to take all their medicines, figure out what they’re supposed to do and where they’re supposed to go. Professional siloes mean there are no whole treatment plans. “Oncology is likely to focus on cancer and may disregard the implications of diabetes. Oncologists may not even be aware that a patient is diabetic.” In this maze, the patient’s best interests are ignored.
Darer says that the traditional care model of patients seeing a different specialist in for each condition rapidly becomes unwieldly for complex patient. “The greater the number of co-morbidities, the more doctors, and the more doctors the greater the chance of communication breakdown and discontinuous care.”
Darer says that the fact that most clinical guidelines are written single diseases contributes to the confusion of providing care for multiple co-morbid patients. Yet he says that for patients 65 and older, 90% of costs are associated with patients with three or more chronic conditions. As our population ages, the numbers of such patients are increasing massively.
Darer also emphasises the importance of continuity of care.
“You really want to ensure as far as possible that the patient sees the same doctors and particularly the same primary care physician. “Over time, doctors can form a clear impression of a patient and what they look like. This means they can identify changes which wouldn’t be spotted by someone coming to the patient for the first time.”
Against this background patients and their families are often struggle to have a clear idea of how best to manage their illnesses. Poor health literacy and pure fatigue can result in disempowerment. For instance, exercising the right to demand palliative care and to quit the guinea pig wheel of appointments and interventions is often difficult, if not impossible.
In order to address the needs of complex patients, Darer prescribes that healthcare organizations need to a) transform their care model to support multiply comorbid patients, b) effectively engage patients-families in their care and c) ensure a flow of impeccable data across the health system.
Darer explains that transforming care delivery requires the transition to coordinated team-based care. Many health systems use case managers to address the needs of their sicker patients, but this practice is often performed as a bit of a one-size fits all band-aid, rather than a true care model transformation. Team-based care brings together a set of clinicians, including clinical pharmacists, clinical educators, home health nurses, clinic nurses, case managers and physicians who work closely to address the needs of patients wherever they are. Team-based care, through protocols and care pathways, also seeks to move safely work away from overworked physicians to the right team members who can now deliver care at lower cost.
In order for team-based care to work, health information systems have to be are able to identify patients with specific care needs and connect that need with the most appropriate clinician, all the while ensuring high-quality communication across entire team. But Darer says that this doesn’t mean vast expenditure on complexity, but rather reconfigurations to ensure that the right people get the right data at the right time
“You need to define the information needs of the pharmacist, the care coordinator, the different physicians, etc., and then ensure your data systems are capturing that data and mobilizing across the care team. When a complex patient is admitted or discharged from a hospital, there are multiple team members who should probably be notified to ensure that the patient’s care plan is updated and continuity reestablished.
Engaging patients and their families as part of the care team Darer says is an essential step to achieving better clinical outcomes. And this starts with increasing the transparency of information such as the OpenNotes initiative.
At Geisinger, , the idea of sharing physician notes with patients and families through an online portal was met with lot of resistance from doctors who feared involving family and patients would take more time and potentially cause harm. The results of the OpenNotes trial, however, showed that patients found access to the information extremely beneficial and the physicians reported no negative impact . 82% of patients looked at their records at least once and 58% opening all their records. “Bear in mind that Geisinger is in rural central and north eastern Pennsylvania where patients tend to be less educated and less wealthy than many communities. Yet still patients and families avidly read their notes.”
Family information requests are often very simple. Darer recalls a focus group discussing the needs of family caregivers for patients with cancer. “The number one request from families was for all of the cancer visits and treatments to be automatically entered into their calendar on their phones so they could plan their lives. Seems like a simple request but many institutions still use paper instructions.”
Like many physicians, Darer is frustrated by certain aspects of current health information technology systems. He says: “Electronic health records were initially designed as transactional systems to enable efficient and reliability billing. They were not designed to meet the longitudinal needs of patients and families with multiple co-morbidities..” He signals out the current system by which physicians write order system in the USA as particularly problematic. “Doctors who order imaging studies frequently fail to adequately communicate to the radiologist the reason for the examination
In some ways, he says electronic healthcare records have become barriers to innovation. “Information security, legal constraints, fears of inadvertent disclosure and the complexity of electronic health record development and maintenance – these issues make information technology departments cautious about enabling appropriate flow of information to support new care models and engage in the kinds of innovation so desperately needed to address the needs of more complex patients.
Ultimately, Darer thinks that healthcare systems need to be able to improve the value of the care they deliver year on year through systems designed to learn. This sounds like a very obvious point, but he says that, in practice, very few organisations systematically assess the clinical outcomes they deliver or the cost it takes to deliver those outcomes. “You would think that at this point in time, we as healthcare professionals should be able to reasonably answer the question – “what impact is the work that we’re doing having on patient health and wellbeing” and learn to improve that impact every year.” Learn what? “Well, figuring out how to dropping the number of avoidable visits to emergency would be a good start.”
Click here to see Jonathan Darer’s presentation at HBI 2018.
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