An important April 24th article published by the Commonwealth Fund is a timely and must-read article. It highlights the challenges of engaging, treating, and support persons with multiple, complex, chronic health conditions (defined as three or more health conditions, often including mental health). It supports the notion the Hogg Foundation believes in: integrated health care, team-based care, care coordination, and relationships: treating people with respect, dignity and worth.
· Persons with multiple, complex, chronic health conditions (approximately 12 million persons) are among the 5 percent of patients who account for about 50 percent of health care spending
· Collectively, these individuals account for more than $120 billion in health care spending annually
· Also possess a functional limitation that interferes with basic activities of daily living
· Persons with multiple, complex, chronic health conditions are impacted by social determinants of health, as well as socio, economic and cultural factors
· A Commonwealth Fund survey of high-need patients found that 44 percent reported delaying care in the past year because of an access problem such as lack of transportation to the doctor’s office, limited office hours, or an inability to get an appointment quickly enough, often leading to more and more expensive care
That said, for all the money spent on multiple, complex, chronic health conditions, it is presumed that this particular patient population is not always receiving the best care or right type of care, where they need it, when they need it, and how they need it. One of the major dilemmas of health care.
Despite the challenges noted above, there are exciting and promising efforts to improve care being implemented, tested and evaluated across the nation. Collaborative, team-based initiatives with care managers such as social workers or nurses working within a medical home type setting show promise.
Many of these test programs have taken a different approach than traditional office care, emphasizing relationship - building and focusing more on meeting patients’ nonmedical needs outside the doctor’s office. Most of these programs pair patients with a dedicated care coordinator, who may or may not have extensive medical training, but who are knowledgeable and understand the complexities of the health care system well enough to help patients successfully navigate it. Importantly, these care coordinators are also strong and effective advocates on behalf of patients for housing, mental health, legal, nutritional, transportation, and other nonphysical/nonmedical needs.
The Commonwealth Fund article highlights innovative programs, patients, and care coordinators in Los Angeles, Chicago, and Minneapolis, just a small sampling of programs involved these kinds of efforts.
In these three case examples, they have several commonalities: improved health outcomes (people get better), increased engagement (people attend clinic appointments; learn about self-management of their conditions), and not requiring less ER visits and hospitalizations (you could argue less cost). Lastly, all examples point to the value and benefit of a care coordinator, who provide frequent “touch points” that do not occur in the clinic or in the health care encounter.
There is increased recognition that non-medical factors that impacts health conditions, such as coping with the day-to-day reality of living with serious, multiple, chronic illnesses, transportation challenges, a stable place to live, knowing where the next meal is coming from, affording the copay for medicines versus buying food, and the list goes on. Largely non-medical issues.
The article concludes that in the same way that medicine had to “learn” to assess and treat patients’ medical and mental health conditions, today’s real challenge is learning to assess and treat patients’ non-medical needs. Integrated health care, team-based care, and care managers, such as the examples illustrated in this Commonwealth article, may be the bridge that connects and strengthens the relationship between the patient and provider.
At the end of the day, it’s about relationship – building. Relationship between provider and patient, relationship between team members, relationship between care manager and patient, and relationships between the patient and their family/caregivers and community. Relationship – building. Not taught in medical schools and in academic graduate training programs. And most importantly, relationship – building does not come in pill form.
Ybarra serves as program officer for the Hogg
Foundation for Mental Health
and leads the foundation’s Integrated Health Care Initiative. With over 25
years of clinical and administrative experience in both private and public
sector behavioral health, Ybarra’s policy and program experience extends to
county, state and national efforts promoting reforms, public policies and
clinical practice to improve effective service delivery and health equity for
racial/ethnic populations. Ybarra joined the foundation in 2007.