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

Abstract

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.

Support for family caregivers: A scoping review of family physician’s perspectives on their role in supporting family caregivers

“…Primary care is credited for better population health, more health equity and better use of resources (Starfield, ). Four key domains are associated with high‐quality primary care: first‐contact access for each need, person focused (not disease) over time, comprehensiveness and coordination of care (Hochman & Asch, ). Vulnerable populations benefit most from quality primary care (Starfield, ) and family caregivers are a vulnerable population (Centers for Disease Control [CDC], ).…”

Reducing ER use through a trainee-designed, interprofessional care group for high-utilizing chronically ill patients: A pilot program

“…17,18 The findings of a cost-neutral program at the conclusion of the pilot are not surprising given the resource investments, and failure to find cost savings is a known possible consequence in similar programs. 13,19 …”

“…11,12 Some, though far from all, programs have demonstrated cost savings for this population. 13 Despite lack of consensus about best practices, the ubiquity of team-based comprehensive care has brought requests for graduate medical education to emphasize related experiences for trainees. 14 …”

Capsule Commentary on Balaban et al., Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System

“…1 Unfortunately, however, complex case management has shown only modest benefits in rigorous evaluations. 1 Nevertheless, research has begun to shed light on which approaches to complex case management offer the most promise.…”

“…1 Unfortunately, however, complex case management has shown only modest benefits in rigorous evaluations. 1 Nevertheless, research has begun to shed light on which approaches to complex case management offer the most promise. Specifically, the most effective programs seem to involve close, interpersonal interaction among care coordinators, patients, and primary care clinicians; a focus on care transitions; a component of medication management; and the targeting of patients amenable to intervention, such as the frail elderly.…”