Improving & Simplifying Care for Patients with Complex Conditions or  Comorbidities

In the US, it is estimated that approximately 10% of patients account for 70% of total direct health care expenses. These patients also incur significant indirect costs due to excess disability, premature or avoidable institutionalization and burden to family caregivers. With the US population aging and health care costs rising, improving care for these patients is more than a moral imperative; it is a matter of economic security. According the US Office of Management and Budget (OMB), in 2009 the US Medicare program accounted for 19% of the US budget ($676 Billion)—second only Social Security, which accounted for 20% ($678 Billion). While care for these patients will never be easy or inexpensive, many quality and cost gaps stem from the lack of alignment between the acute care-oriented US health care system and the needs of people with chronic conditions—or end-of-life issues. Experts from Dartmouth and other institutions have found that care for patients with complex conditions and comorbidities is routinely uncoordinated, fragmented and often unnecessary (particularly in the last six months of life).

Effective and efficient care for patients with complex conditions or comorbidities will require more than new models and programs—it will require a culture change in health care and the readiness and willingness of health care professionals and associations to work across the silos of care settings and disciplines to implement solutions that are truly patient-centered, whole-person and interdisciplinary. The “interdisciplinary team” will need to be more than aspiration or motto, but instead will require a shared practice platform, formal partnerships, and written protocols for coordinating care, exchanging information and evaluating performance. While care oversight, coordination and care management have shown great value, they will simply be workarounds or stopgap measures unless we can encourage real teamwork and integration across the silos of care in our communities. Incentives will need to change as well. The Accountable Care Organization (ACO) is one promising model that bases reimbursement on patient-level quality and costs outcomes and rewards providers for working collaboratively to deliver better value.

Better care will also require improved application of evidence-based medical practices—and evidence-based care management and health coaching practices. In a 2009 New England Journal of Medicine article referenced in the HealthSciences Institute Fall 2009 eNews, Bodenheimer and Berry-Millet conducted a thorough review of the case management literature and made six key recommendations for improving the effectiveness of complex care management. Two of the six recommendations focus specifically on building a nurse workforce formally trained in chronic care management and self-care support. While most health and care management professionals are well aware of gaps in evidence-based medical care, they may be less aware of gaps in evidence-based health management or care management practice. Yet, chronic care is widely recognized as a new model of care that requires new competencies according to chronic care experts, the Institute of Medicine and the World Health Organization, among others.

We cannot transform health care unless we also support our patients in being successful self-care managers. However, for many patients with complex conditions or comorbidities, the burden of care often reduces capacity to fully partner in their care. A seminal paper titled We Need Minimally Disruptive Medicine published in August 2009 in the British Medical Journal by Mayo Clinic endocrinologist and professor of medicine, Dr. Victor Montori and UK professors Carl May and Frances Mair introduced the concept of minimally disruptive medicine in the care of individuals with complex chronic conditions. These authors note: “Chronic disease is the great epidemic of our times, but the strategies we have developed to manage it have created a growing burden for patients. This treatment burden induces poor adherence, wasted resources, and poor outcomes. Against this background, we call for minimally disruptive medicine that seeks to tailor treatment regimens to the realities of the daily lives of patients. Such an approach could greatly improve the care and quality of life for patients.”

Minimally disruptive medicine offers a new perspective on how we can enable patients to become better care managers and use health care resources wisely. On August 6th at 10:30 (CT) we are pleased to host Dr. Victor Montori of Mayo Clinic at our Population Health Improvement Learning Collaborative meeting. Please join us as we learn more and define steps for applying minimally disruptive medicine in population health improvement. Learn more or register now for this free session. Visit www.minimallydisruptivemedicine.org to learn more about minimally disruptive medicine.

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