Interdisciplinary Models of Care for High-Risk Patients

OBJECTIVES

Objectives

Review the limitations of “one-on-one” model of care for socially complex, chronically ill patients who are frequently admitted to the hospital.
Describe the key components of interdisciplinary models of care for high-risk patients
Review case studies of interdisciplinary programs for high-risk patients.

INTRODUCTION

Five percent of patients account for 50% of health-care costs.^1,2 These patients are often poor and have high rates of chronic disease, mental illness, and/or addiction.^2,3 Even when health-care services are readily available, many patients face multiple barriers to effective care such as homelessness,⁴ low literacy,⁵ social isolation,⁶ language barriers,⁷ addiction,⁸ and mental illness.⁹ These barriers to health care result in high rates of emergency department care and hospitalization, which drive the high costs of care in this population.^1,2

There are many interdisciplinary models of care in the United States that have successfully decreased utilization and cost for patients at high risk for frequent hospitalization. They all include interdisciplinary teams in which both medical and nonmedical professions partner together to improve care for patients. Team members may include physicians, nurses, nurse practitioners, social workers, physical and occupational therapists, community health workers, health educators, pharmacists, psychologists, and other health professionals. These teams proactively identify the highest risk patients, create an interdisciplinary care plan that includes care coordination, and monitor how each patient is meeting the care plan goals.¹ These innovative, interdisciplinary models of care improve outcomes and costs by helping patients overcome personal vulnerabilities as well as social and health system barriers to effective care.²

This chapter discusses the concepts underlying these interdisciplinary models of care for high-risk patients, and describes specific programs. While the concept of providing interdisciplinary care for high-risk patients underlies all of these models of care, the different models may use different words to describe their work. Case management, complex care management, ambulatory intensive care units (ICUs), and care coordination are all terms that individual programs use to describe their work improving outcomes for high-risk populations using interdisciplinary teams. Throughout this chapter, we use “interdisciplinary models of care” to describe all of these types of programs. However, in each case example, we use the particular words that each program uses to describe itself.

FAILING CURRENT CARE

Mr. Beltran is a 56-year-old man who works as a day laborer but is unable to find a steady job. Living in homeless shelters, he becomes increasingly depressed, and begins to drink heavily. After visiting the emergency room and being diagnosed with diabetes, he is referred to the resident clinic at the county hospital. Here he has difficulty attending scheduled appointments with his primary care provider because of his unpredictable work schedule and his alcohol addiction, so he drops into clinic only when he is sick. In these visits, physicians who do not know him well adjust medications that are rarely filled, order laboratory tests that are rarely drawn, and write “lost to follow-up” over and over in the chart. The clinic nurse refers him to a Spanish-speaking social worker; he does not qualify for financial benefits because he is not disabled, and there are no options for subsidized housing.

After 10 years of intermittent outpatient care, Mr. Beltran is hospitalized many times with recurrent episodes of diabetic ketoacidosis, chronic diarrhea, pancreatitis, chronic pain, and bladder obstruction requiring an indwelling Foley catheter.

After each hospitalization, he is discharged to the streets with follow-up in the resident clinic. Living on the streets with an indwelling catheter, chronic diarrhea, uncontrolled diabetes, and little access to food, water, and sanitation, Mr. Beltran is admitted to the ICU with urosepsis.

Mr. Beltran’s story raises many questions. Why is he requiring frequent hospitalizations and becoming more ill despite access to primary care? What could his primary care physician do to increase the effectiveness of the medical care Mr. Beltran is receiving? What could other models of care offer him that the current system does not?

Conventional medical care often consists of short appointments, spaced months apart with a primary care clinician who must address multiple problems. This model works well for many people. However, for some people with chronic diseases—certainly for those who suffer from poverty, mental illness, or drug addiction—this model is fraught with challenges for patient and clinician alike.

The 5% of people in the United States who account for 50% of health-care costs share similar characteristics with Mr. Beltran—they often have complex medical problems, are poor, and have mental illness and/or addiction.^1,2 In many areas, patients such as Mr. Beltran do not have access to primary care, but a study in San Francisco showed that in this locality, patients similar to Mr. Beltran actually had very high rates of contact with the health-care system, yet they were not in treatment for addiction, and continued to be seen frequently in the emergency department and admitted to the hospital.¹⁰

Even though these patients’ needs are not being met by the current health-care system, what they need to be healthier and stay out of the hospital is understandable. In Mr. Beltran’s case, access to housing, a bathroom, and food may have prevented his ICU stay. For other patients, durable medical equipment, ongoing one-on-one self-management coaching in the patient’s native language, transportation, or medication delivery could significantly improve their health. Given the high rates of chronic disease, mental illness, and addiction in high-risk populations, the lack of integration between services for these problems creates often insurmountable and unnecessary barriers for these patients.²

Common Pitfalls: Delivering Quality Care To High-Risk, High-Cost Patients Systems Factors

Poorly integrated medical, psychiatric, and addiction services.
Social services are either unavailable or operate independently from medical care, leading to gaps and redundancy in care.
Insufficient self-management coaching leaves patients without the resources to manage their chronic conditions.
Inadequate support with complicated medication regimens leads to medication errors and nonadherence.
Poor access to transportation may limit patients’ ability to follow-up.

Patient Vulnerabilities

Competing personal priorities (the search for food, housing, and safety) interfere with accessing medical care.
Mental illness and/or substance use interfere with patients’ abilities to follow through on treatments and appointments.
Lack of social support makes self-management challenging and reduces capacity to adapt to stressors.
Poor access to sanitation and hygiene makes some patients embarrassed to seek care.

Provider Factors

Providers are overwhelmed by the patient’s complex social situation and doubt that the social issues can improve.
Providers fail to recognize and leverage patient’s strengths and resiliency factors.
Overcoming language differences between patient and provider may prove too cumbersome for both patient and providers.
Real or perceived cultural biases may impede effective alliances between patients and providers.

WHAT IS THE HISTORY OF INTERDISCIPLINARY MODELS OF CARE FOR HIGH-RISK PATIENTS?

Interdisciplinary models of care for high-risk patients evolved out of two very distinct challenges to health care: (1) the deinstitutionalization of severely mentally ill patients in the 1960s and 1970s with the closing of mental health facilities and (2) the increasing costs of frequently hospitalized chronically ill patients in the 1980s.

In response to deinstitutionalization, interdisciplinary community-based programs focused on the severely mentally ill were created to provide a full range of services, from housing to psychiatric care for these patients. In response to the rising costs of caring for frequently hospitalized chronically ill patients, the Centers for Medicaid and Medicare Services (CMS) launched demonstration projects among Medicare recipients: nurse case management focused on specific chronic diseases, such as congestive heart failure, improved care for patients with those diseases.²

These two innovations in health care led, in the 1990s, to Health Maintenance Organizations (HMOs) adopting elements of CMS nurse case management in an attempt to control health-care costs, often hiring outside vendors to provide nurse case management telephonically to their members who had specific diseases. Ultimately, these HMO and vendor programs were unsuccessful in improving chronic disease care or controlling costs.¹¹ Lessons gleaned from this experience were that models work better when they are more tightly linked to primary care and include an in-person element.^12,13

Complex care management evolved to focus on patients with multiple diseases, rather than just a single disease, who were at high risk of hospitalization. This evolution was driven by the success of the CMS demonstration programs, the failure of vendor disease management, and the changing incentives in health care.^12,14

Mr. Beltran survived his hospitalization and was referred to a high-user case management program. A Spanish-speaking case manager finds him a respite bed in a shelter. The registered nurse in the program puts together a medi-set that is delivered on a weekly basis. He is also reminded of his medical appointments and escorted to them by a team member. His primary provider adds antidepressants and nutritional supplements to his treatment. Eventually, permanent housing in a senior supportive housing facility is found for him. He is taught to use a glucometer and to straight catheterize himself. After a few months in the program, he has no further hospitalizations.

HOW DOES IT WORK?

EFFECTIVE TEAMWORK

In 2001, the Institute of Medicine’s Committee on the Quality of Health Care issued a report in which a major theme was the importance of using teams to deliver quality care to patients.¹⁵ Physician education, training, and testing are just beginning to include education in working on teams. Evidence suggests that effective teamwork does not arise spontaneously, but rather requires specific skills and development.

People tend to think of a team as simply being a group of people working together, but as one observer noted, “It is naïve to bring highly skilled professionals together and assume that, by calling this group a team, it will act like a team.”¹⁶

Common barriers to working well as a team are goal conflict, role conflict, and poor decision making (see “Core Competency

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