Tailoring Complex Care Management for High-Need, High-Cost Patients

Blumenthal, David; Abrams, Melinda K.

doi:10.1001/jama.2016.12388

Cited by 96 publications

(86 citation statements)

References 3 publications

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“…As such, it offers a repository with sufficient size and scope to support analyses of detailed clinical care and assessments of important subgroups of patients, such as those with serious illness, including ''high-cost, high-need'' patients who particularly benefit from palliative care. 13,[21][22][23] In addition, EHR data are recorded directly from documentation of healthcare delivery and utilization without requiring additional data entry beyond that accompanying routine care. The EHR also captures social determinants of health, which are important to the delivery of high-quality, accountable care for the seriously ill. 24 Alongside these strengths, the EHR has important limitations.…”

Section: Strengths and Weaknesses Of The Ehr For Palliative Care Qualmentioning

confidence: 99%

Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

Curtis

Sathitratanacheewin

Starks

et al. 2018

Journal of Palliative Medicine

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Background: As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. Methods: In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. Results: In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of communityand population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. Discussion: Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.

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Section: Strengths and Weaknesses Of The Ehr For Palliative Care Qualmentioning

confidence: 99%

Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

Curtis

Sathitratanacheewin

Starks

et al. 2018

Journal of Palliative Medicine

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“…6 Nevertheless, we believe that modest policy changes could substantially increase the availability of primary care resources for HNHC populations. 51 First, there is a need for changes in how care for HNHC populations is reimbursed. Traditional fee-for-service payment provides only limited reimbursement for the intensive services HNHC populations need, and programs that do cover these services like the Medicare care management fee 47 are available in only a small number of situations.…”

Section: Policy Changes To Improve Care For High-needs High-cost Patmentioning

confidence: 99%

“…Still, to provide health system leadership with data to justify investments in programs for HNHC patients, as well as to ensure that these programs are designed efficiently, it will be necessary to make these research investments. 51 Fortunately, many of the reforms we have suggested are already under way. In some regions, health care delivery organizations are accepting more financial risk and accountability for their populations.…”

Section: Policy Changes To Improve Care For High-needs High-cost Patmentioning

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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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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“…7 Furthermore, with a gradual shift toward value-based reimbursement models that measure the quality and cost of health care delivery, clinical efficiency is an increasing concern for physicians who work in outpatient settings. 3,8–10 …”

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confidence: 99%

Association of the Presence of Trainees With Outpatient Appointment Times in an Ophthalmology Clinic

et al. 2018

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IMPORTANCE Physicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known. OBJECTIVE To quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic. DESIGN, SETTING, AND PARTICIPANTS This single-center cohort study was conducted from January 1 through December 31, 2014, at an academic department of ophthalmology. Participants included 49 448 patient appointments with 33 attending physicians and 40 trainees. EXPOSURES Presence vs absence of trainees in an appointment or clinic session, as determined by review of the EHR audit log. MAIN OUTCOMES AND MEASURES Patient appointment time, as determined by time stamps in the EHR clinical data warehouse. Linear mixed models were developed to analyze variability among clinicians and patients. RESULTS Among the 33 study physicians (13 women [39%] and 20 men [61%]; median age, 44 years [interquartile range, 39-53 years]), appointments with trainees were significantly longer than appointments in clinic sessions without trainees (mean [SD], 105.0 [55.7] vs 80.3 [45.4] minutes; P < .001).The presence of a trainee in a clinic session was associated with longer mean appointment time, even in appointments for which the trainee was not present (mean [SD], 87.2 [49.2] vs 80.3 [45.4] minutes; P < .001). Among 33 study physicians, 3 (9%) had shorter mean appointment times when a trainee was present, 1 (3%) had no change, and 29 (88%) had longer mean appointment times when a trainee was present. Linear mixed models showed the presence of a resident was associated with a lengthening of appointment time of 17.0 minutes (95% CI, 15.6-18.5 minutes; P < .001), and the presence of a fellow was associated with a lengthening of appointment time of 13.5 minutes (95% CI, 12.3-14.8 minutes; P < .001).CONCLUSIONS AND RELEVANCE Presence of trainees was associated with longer appointment times, even for patients not seen by a trainee. Although numerous limitations to this study design might affect the interpretation of the findings, these results highlight a potential challenge of maintaining clinical efficiency in academic medical centers and raise questions about physician reimbursement models.

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Tailoring Complex Care Management for High-Need, High-Cost Patients

Cited by 96 publications

References 3 publications

Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

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

Association of the Presence of Trainees With Outpatient Appointment Times in an Ophthalmology Clinic

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