Primary care is increasingly geared toward standardized care and decision-making for common chronic conditions, combinations of medical and mental health conditions, and the behavioral aspects of care for those conditions. Yet even with well-integrated team-based care for health conditions in place, some patients do not engage or respond as well as clinicians would wish or predict. This troubles patients and clinicians alike and is often chalked up informally to "patient complexity." Indeed, every clinician has encountered complex patients and reacted with "Oh my gosh"-but not necessarily with a patterned vocabulary for exactly how the patient is complex and what to do about it. Based on work in the Netherlands, patient complexity is defined here as interference with standard care and decision-making by symptom severity or impairments, diagnostic uncertainty, difficulty engaging care, lack of social safety or participation, disorganization of care, and difficult patient-clinician relationships. A blueprint for patient-centered medical home must address patient complexity by promoting the interplay of usual care for conditions and individualized attention to patient-specific sources of complexity-across whatever diseases and conditions the patient may have.
T his report addresses the influence of family relationships on the manage-ment and outcomes of chronic disease. We limit our consideration to disorders conventionally referred to as medical rather than psychiatric or behavioral. We include diseases that require continuing management and diseases that pose a continuing threat of recurrence.The goals of this report are to describe a theoretical model of linkages among family relationships, disease management, and chronic-disease outcomes; to provide an overview of the literature on family factors that are known to influence chronic disease, on the basis of empirical data; to review family-focused intervention trials in chronic disease; and to provide a set of recommendations for the next stage of research on family interventions aimed at improving the management of chronic disease.
An Institute of Medicine committee was convened to explore the links between biological, psychosocial, and behavioral factors and health and to review effective applications of behavioral interventions. Based on the evidence about interactions of the physiological responses to stress, behavioral choices, and social influences, the committee encouraged additional research efforts to explore the integration of these variables and to evaluate their mechanisms. An understanding of the social factors influencing behavior is growing and should be considered in programs and policies for public health, in addition to individual behavior and physiological status. Interventions to change behaviors have been directed toward individuals, communities, and society. Many intervention trials have documented the capacity of interventions to modify risk factors. However, more trials that include measures of morbidity and mortality to determine if the strategy has the desired health effects are needed. Behavior can be changed and new behaviors can be taught. Maintaining behavior changes is a greater challenge. Although short-term changes in behavior following interventions are encouraging, long-duration efforts are needed to improve health outcomes and to provide long-term assessments of effectiveness. Interventions aimed at any level can influence behavior change; however, existing research suggests that concurrent interventions at multiple levels are most likely to sustain behavior change and should be encouraged.
The world of primary care was galvanized in 2007 by the publication of the Joint Principles of The Patient-Centered Medical Home (PCMH) that spells out the fundamental features of a primary health care setting in which a team of clinicians offers accessible first-contact primary care. 1 This care should be personal, coordinated, continuous, and comprehensive-it should address most or all of a person's health care needs. Comprehensiveness confers value to the PCMH, and is an especially important principle. 2 By some means, "all of a person's health care needs" must be addressed in the PCMH. This cannot be achieved without including the behavioral aspects of health. Yet comprehensiveness often is not achieved in PCMH efforts because behavioral issues are not addressed. This shortfall requires redress.
PURPOSE We wanted to identify risk factors for persistently high use of primary care. METHODSWe analyzed outpatient offi ce visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997-1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confi rmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTSTwo percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confi rmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONSMany persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefi t from psychosocial support, whereas others may be good candidates for disease management interventions. INTRODUCTIONT he well-known concentration of health care utilization and costs among relatively few individuals 1 allows for targeted interventions and modeling of patient risks for more equitable health care reimbursement.2-4 Factors associated with high utilization include patient demographics, previous use of health care, patient diagnosis, and severity of illness. 5,6 If certain patient characteristics are predictive of high persistent use, it may be possible to offer more cost-effective alternatives to frequent primary care visits, including disease management, case management, group visits, and patient education. [7][8][9][10][11] Better management of persistent primary care use may better address the patients' underlying problems, reduce unnecessary demand, and relieve some of the pressure on the capacity of primary care providers to deliver care to all patients. 12,13 Most efforts to identify and adjust for patients with high expected health care use have been directed at predicting total health care expenditures 3,6,14,15 METHODS Study Site and Patient PopulationThe study population included approximately 58,000 people continuously insured with a fee-for-service plan in a small urban area in the midwestern United States. Patients who did not authorize research use of their...
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