Caring for High-Need, High-Cost Patients — An Urgent Priority

Blumenthal, David; Chernof, Bruce; Fulmer, Terry; Lumpkin, John R.; Selberg, Jeffrey D

doi:10.1056/nejmp1608511

Cited by 271 publications

(266 citation statements)

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“…5 Such patients commonly report high levels of frustration with the care delivery system, and may experience avoidable complications resulting from disjointed, inaccessible, and poorly aligned care. 6 Because Bhigh-needs^patients require extensive attention and services, they also consume a disproportionate share of resources. 7 In many populations, approximately 80% percent of medical expenditures are concentrated within 20% of patients and 50% of costs within 5%.…”

Section: Introductionmentioning

confidence: 99%

“…1). 12 While improving care for HNHC patients represents an important opportunity, 6 it also presents a formidable challenge, particularly for traditional office-based primary care practices that lack the multidisciplinary resources these patients so often need. 13 Primary care clinicians in such clinics often feel ill-equipped to manage HNHC patients, 14 and may abdicate their role in overseeing their care.…”

Section: Introductionmentioning

confidence: 99%

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Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Hochman

Asch

2017

J GEN INTERN MED

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Starfield and colleagues have suggested four overarching attributes of good primary care: Bfirst-contact access for each need; long-term person-(not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere.^As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for highneeds, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Hochman

Asch

2017

J GEN INTERN MED

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“…3 But regardless of how high-cost patients are categorized, a multifaceted approach is surely required, as Lee et al suggest, involving distinct interventions (e.g., violence prevention for trauma patients; coordinated medical, mental, and social services for patients with SMI; palliative care for terminal cancer patients) to address distinct health needs and their associated costs. 3,4 Lee et al thus appropriately ask us to consider "a more comprehensive approach that addresses" other high-cost categories identified in their study. Clients receiving ambulatory cancer treatment, surgical joint replacement patients, and users of critical care, for example, are each clearly big-ticket users.…”

Section: Is Any Of This a Surprise?mentioning

confidence: 99%

“…11 These particular interventions are often aimed at hotspotters, but many effective care management programs apply to a diverse spectrum of complex, high-cost patients. 4,11 Such programs embrace the key role of care coordination and also customize interventions to match patient needs. They can result in improved patient-oriented outcomes and enhanced provider experience, as well as cost reduction.…”

Section: Is Any Of This a Surprise?mentioning

confidence: 99%

Hot-Spotters Aren’t “The Problem”...But They Are Emblematic of the Failure of U.S. Healthcare

Kanzaria

Hoffman

2016

J GEN INTERN MED

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“…Attention to this question of how to best serve high-need patients continues to increase, 3 and success in intervening to improve care transitions for this population is limited, 4 in part because providing more care and more coordination requires more resources. Observing the challenges that remain for patients treated in the highly-resourced setting that is Casey House, the authors propose a previously described theoretical construct, minimally disruptive medicine (MDM), 5 as a framework to guide patients and providers in creating a discharge plan that relies on the patient's capacity to integrate disease self-management into his or her daily circumstances.…”

mentioning

confidence: 99%

A Problem of Capacity, but Whose? The Hospitalists' Discharge Dilemma and Social Determinants of Health

Mosher

Lyckholm

2017

Journal of Hospital Medicine

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For a number of years, those challenged with improving discharge transitions and preventing readmissions have suggested more-more case managers, more checklists and systems, more discharge pharmacists; and better-better communication, better medication reconciliation, better discharge documentation, better follow-up. In a study by Chan Carusone et al., 1 high-need, high-complexity patients receiving treatment at Casey House, a specialized urban hospital providing inpatient and community programs, were afforded a full complement of discharge planning and posthospitalization services. Despite these services, the patients achieved little success in maintaining their health and following their discharge plans after hospitalization.This longitudinal qualitative study detailing the lived experience of discharge extends our knowledge of challenges faced by patients during the posthospital transition, 2 and further elucidates the differences between patients' expectations and assessments of their resources and goals, and their actual abilities and priorities on discharge. Despite substantial assistance, including housing, food assistance, and case management, Chan Carusone et al. found that the exigencies of day-to-day existence exceeded the patients' capacities to sustain themselves outside the hospital. This failure implies a question: If the interventions alluded to in this study were not enough, then how much more, and how much better, is needed?Attention to this question of how to best serve high-need patients continues to increase, 3 and success in intervening to improve care transitions for this population is limited, 4 in part because providing more care and more coordination requires more resources. Observing the challenges that remain for patients treated in the highly-resourced setting that is Casey House, the authors propose a previously described theoretical construct, minimally disruptive medicine (MDM), 5 as a framework to guide patients and providers in creating a discharge plan that relies on the patient's capacity to integrate disease self-management into his or her daily circumstances. MDM hinges on the concept of balancing workload and capacity: the burden of managing disease

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Caring for High-Need, High-Cost Patients — An Urgent Priority

Cited by 271 publications

References 1 publication

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Hot-Spotters Aren’t “The Problem”...But They Are Emblematic of the Failure of U.S. Healthcare

A Problem of Capacity, but Whose? The Hospitalists' Discharge Dilemma and Social Determinants of Health

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