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Complex Patients: Positioning Teams for Best Outcomes

Posted By Matthew P. Martin, Monday, April 16, 2018


Patients living today with both complex medical and behavioral health problems are expected to die 25 years earlier than the general population.1 These patients have more medical problems than the general population and a disease burden that increases as behavioral health problems increase. Most patients with behavioral health problems are seen in non-psychiatric medical settings like primary care.2 Untreated behavioral health problems make it challenging for patients to improve their overall health.

Care management, a collaborative process of assisting and supporting patients, is a cost-effective approach for helping patients with complex health problems;3 however, most case management services focus solely on medical or behavioral health problems and do not always involve the primary care physician. The East Tennessee University Department of Family Medicine recently presented a regional conference on strategies for treating complex patients. Therese Narzikul, a gerontological nurse practitioner, was a co-presenter and helps answers some questions below about working with this patient population.

1. What are some of the challenges and barriers to treating complex patients?

Some of the challenges and barriers-or as I like to reframe these—the opportunities that we have in treating complex patients lie within the way the current system is designed. Structurally the system is set up for the average patient. The time allotted is generic and not geared for the complexity of the person. In fact the complexity/unique context of the person is rarely adequately explored or understood. We often do not ask the patient what matters to them and what are their life/health goals to ensure we create a plan that incorporates their perspective. The more complex a patient is-the more important the alignment and integration of the patients’ perspective with the plan.
The visit itself is problem-focused but often fails to appreciate the problem as an outcome of a complex system of interactions that are never fully explored or exposed—we treat the symptom. In science we break systems apart to make sense of them. With complex patients it is critical that we look at them as a whole in order to understand them. The dynamic nature of any complex system-biological/socio-cultural-makes their “problems” unpredictable and multidimensional. We have an opportunity to further develop care teams to explore and expose the relationships and connections and emerging outcomes for complex patients. This will provide the needed context to design interventions tailored for these dynamic, unpredictable and multi-dimensional complex patients and populations.

2. What are some prominent team-based practice models for assisting complex patients?

There are lots of super frameworks out there for assisting complex patients. The GRACE Model, Guided Care Model, The Transitional Care Model, etc…. The key to deploying any model is appreciating and designing it within the context of the organization and/or community as well as the population for which it is aimed to assist.
Taking time to understand the context provides key insights into model selection and implementation. In addition to the model selected and equally important is the underlying operating principles and appreciation of the role of shared vision, shared purpose, shared leadership, and shared understanding in enabling the team. In an environment that is focused on learning and improvement, the power of the individual and collective team perspectives can be shaped to design emerging solutions to the dynamic nature of complex patients and populations. Team members want to feel they are a part of things and want to have a hand in shaping the future. Leaders that create this environment for team-based practice models will be as successful as the teams.

3. What practice change targets can managers use to measure improvement in their practices?

It all backs up to what they want to accomplish? For whom? And Why? In healthcare practices we are trying to create value for our patients. Patients like practices value time, money and knowledge. They would like to get the best outcome without having to incur more time or money than necessary. The outcomes they want are to stay healthy, live with illness (if they have any) and get better (if they are sick). Change targets to measure improvements would be tied to the outcomes that help patients achieve these goals in the most efficient (least time, lowest cost) and effective (safe, equitable, patient-centered) manner. Do the patients at their practices get all the recommended care and services to keep them the case of complex (more vulnerable patients): provide these to prevent their chronic conditions from worsening or an acute condition from impacting them more seriously? Etc…

4. What financial models or strategies help to maintain sustainability with treating this patient population?

Financial models and strategies need to be developed within the context of the organization, region and market. If an organization looks to design interventions where you get 3 for one and one of the 3 generates new revenue that is the best design. A design where all stakeholders win. The payer gets something they need, the provider gets something they need, the patient gets something they need, the community gets something they need, the care team members get something they need… For complex patient, an intervention that accurately assesses and addressed the patient complexity, incorporates the perspective of the patient and pertinent team, captures and communicates the risk/complexity to the payers (on an claim) and to other providers in the extended care teams (with EMR) and creates short-term (new revenue) and long-term value (triple aim impact) for the organization.

1. Parks, J., Svendsen, D., Singer, P., Foti, M. E., & Mauer, B. (2006). Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, 25(4).
2. Kessler R., Stafford D. (2008) Primary Care Is the De Facto Mental Health System. In: Kessler R., Stafford D. (eds) Collaborative Medicine Case Studies. Springer, New York, NY.
3. Smith, S. M., Wallace, E., O'Dowd, T., & Fortin, M. (2016). Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. The Cochrane Library.


Therese DeVries Narzikul is Vice President of Practice Design & Care Coordination at Jefferson Health where she is largely focused on designing care delivery to improve health, experience of care and health outcomes, with a special focus on vulnerable patients and populations.  As Gerontological Nurse Practitioner with an MBA, Therese provides expertise in the areas of care delivery system transformation, population health and risk management, care coordination across the continuum and performance improvement.

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