Director's Corner: The National Academy of Medicine Points the Way to Improved Care for High-Needs Patients

  ·  Health Policy Hub   ·   Ann Hwang, MD

 

Last week, I had the honor of speaking at the National Academy of Medicine in Washington, D.C., at the release of the Academy’s new special report, “Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.” This report focuses on patients with high medical needs, and advances insights and perspectives on how to improve their care. I had the opportunity to respond to the report and I wanted to share a few of my reflections.

First, the report calls attention to an important fact: the health care system is failing the very people who need it most. The report notes that high-need individuals are more likely to suffer from care that is not coordinated and to have unmet medical needs. For those of us who spend a lot of time in the health care system, whether as patients, caregivers or providers, this is not surprising. Trying to get appropriate care when you or a loved one (or your patient) has a complex set of needs exposes all of the gaps and shortcomings in our health care system. We must do better, and this report provides a tremendous amount of data and evidence to guide our way forward.

Second, an important step for improving care is to identify the patients with high needs who are suffering from poor care. The report presents a starter “taxonomy” of high-needs patients. But one of the report’s findings – that health care consumers know when the system is failing them – presents the possibility of an alternative approach. Instead of starting from the claims data in the hopes of getting to the person, why not start with the person? This means identifying a simple set of two or three questions that could allow providers, patients and caregivers to identify who has high needs and is at high risk for getting inadequate care. These questions – perhaps derived from measures of patient activation, patient confidence, health status and care quality –could serve to identify those consumers who might benefit from an intervention, such as enrollment into an enhanced-care coordination program. This, to me, seems a much more direct method to identify who is at risk, and one that can be applied at any point of contact with the system.

Third, in order to be successful, the work to improve care for people with complex needs must have a laser-like focus on consumers and caregivers. While the report identifies organizational attributes of successful care models for consumers with complex needs – including leadership, customization, team relationships, training, continuous assessment and data use – I would argue that these are the strategies, not the vision. A clear and shared vision of patient-centered care is necessary to carry out the hard work of transformation, otherwise we risk this vital endeavor becoming reduced to a “check the box” exercise without fundamentally changing the culture of health care so that it focuses on taking care of a person, in partnership with that patient and their caregivers.

Fourth, consumers should be full and engaged partners in the development and implementation of these models of care. We have seen some of this great work by our consumer advocates and community partners working on their states’ the dual eligible demonstration projects, and in the Center’s Consumer Voices for Innovation program. We’d love to see this focus on engagement become standard practice. In the same way that policymakers now routinely incorporate technical assistance and outreach to providers as they adopt new models of care, I would like to see technical assistance and outreach to consumers as they participate in these models. In this work, we must be mindful that some people and communities face greater barriers to engagement, and focus on addressing disparities in engagement and access.

Finally, the publication of this report in the midst of a pitched battle about health care coverage in this country raises a pointed question: what will happen to care for people with complex needs if they lose health care coverage? Just as we see this great progress toward improving care for those who are most at risk – frail elders, people with complex conditions, people who face social as well as health challenges – there are tremendous changes proposed to health coverage and the funding of Medicaid in this country that threaten the care for exactly these populations.

We can and should work to improve care for those with high needs and protect the coverage that is the foundation of this care. This report is a wonderful acknowledgement of the work done to date and an encouragement to all of us as we forge the path forward. I believe that the expertise of consumers – particularly those with complex needs and their caregivers – can help our country collectively write the next chapter in this journey toward better care, for everyone.