Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

Abstract

PURPOSE Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODSWe conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTSThe 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses.CONCLUSION This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. INTRODUCTIONP rimary care physicians (PCPs) play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. Algorithms that focus on numbers of conditions, medications, or both, however, may not align with clinicians' definitions of complexity.1,2 Early definitions of patient complexity focused on those factors.2,3 Newer models of complexity have been developed that incorporate mental health, social influences, and economic factors that substantially affect chronic disease outcomes. [4][5][6][7][8][9][10][11][12][13][14] For example, building on the work of Stiefel et al 10 with the INTERMED instrument, Peek et al 4 developed the Minnesota Complexity Assessment Method, which assesses 5 domains: illness (both medical and mental illness), readiness to engage, social, health system, and resources for care. It is unclear, however, whether PCPs' perceptions of complexity are aligned with these newer models.If endorsed by PCPs, newer models of complexity could potentially contribute to improving algorithms for risk adjustment for primary care patient panels, controlling for complexity in secondary database analysis, and designing interventions for complex patients. To inform the clinical application of new models of care for complex patients, we sought to understand how PCPs conceptualize patient complexity and to develop a corresponding typology. METHODSWe used a qualitative study design to conduct in-depth, open-ended interviews with PCPs. Using systematic nonprobabilistic sampling to achieve a 452balanced distribution of sex, years in practice, and type of practice, we recruited physicians from 2 university clinics and 3 community health clinics. 15 We limited o...

The complex patient: A concept clarification

“…Complexity varies in its articulation regarding what exactly is complex about the patient. Social determinants of health, as articulated in internal medicine and gerontology, name socioeconomic, cultural, biological and genetic, environmental, and behavioral aspects of individual health as sites of complexity (Safford et al, ; Loeb et al, , ). Nardi et al () define complexity as it relates to patients as “an alternative model in which illness (and health) result from complex, dynamic, and unique interactions between different components of the overall system.” (P362) They further argue that complexity results from the “intricate entanglement of two or more systems (e.g., body‐disease, family‐socioeconomic status, therapies)” (P362) (Nardi et al, ).…”

Complex Care Needs in Multiple Chronic Conditions: Population Prevalence and Characterization in Primary Care. A Study Protocol

“…To date, only one study has defined the complexity of the patient from the perspective of a primary care professional [14]. Another study has added qualitative detail that supports and expands on the previous cohort study by Grant et al [15]. …”

“…Grant et al suggest different complexity patterns where mental health and substance abuse were identified as the main problems in younger complex patients, while decision-making and care coordination predominated in advanced age [14]. Loeb et al perceive complexity if patients have an exacerbating factor—a medical illness, mental disease, socioeconomic challenge, or behaviour or trait (or some combination thereof)—that complicate care for chronic health conditions [15]. …”

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices

“…Current widely used methods to characterize high-risk patients focus on claims-based algorithms that account primarily for health care utilization patterns. 8 These methods do not necessarily align with clinicians' definition of complexity, which includes behavioral, social, and economic needs. [9][10][11][12][13] Moreover, busy primary care practices may need longer than 1 year to create new workflows to review empaneled patients, categorize patients into different risk tiers, and establish care management services.…”