Caring for High Need Patients

Alan R. Weil Health Affairs Editor-in-Chief, opened the Health Affairs Forum “Community Care for High-Need Patients” to discuss articles appearing in the June 2019 issue of Health Affairs. The conversation centered on the best ways to provide care outside of traditional medical settings for people with advanced illness.

A panel of authors presented their ideas and thoughts on how to meet the needs of the aging population in the 21st Century. The June issue is devoted to understanding ways to recruit, train, and deploy the necessary clinical and non-clinical workforce and to fully integrate family caregivers into the care process.

Opening the panel discussion on developing and providing high quality care teams, Courtney Harold Van Houtven, PhD Research Scientist, Center for Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Health Care System discussed the article, “A Path to Achieving High Quality Team-Based Care for People with Serious Illness”. She suggests that teams caring for people with serious illnesses may function best when the team participants are able to meet virtually.

She also discussed the term “Complexity Science” which is referred to as the study of complex systems and the relationships and interconnections among a system’s components rather than the individual components.

Recently complexity science is being used in healthcare as a means to bring lessons learned from effective teams in other industries and apply lessons learned on how to handle complex patient care problems. Complexity science research relies on the vitality of the connections among people, cognitive diversity, and the ability to track the rate and use of information flowing through the system.

Once the network of connections is established, the information flows more easily through the system. However, serious barriers to information flow still remain. Since team care can require information coming from different documentation formats, problems in submitting the correct data to EHRs can result in not being able to locate relevant information quickly in EHRs.

Carolyn C. Foster MD, ccfoster@luriechildren’ Assistant Professor of Pediatrics, Northwestern Feinberg School of Medicine, and Attending Physician at the Ann and Robert H. Lurie Children’s Hospital of Chicago, discussed the article “Home Health Care for Children with Medical Complexity: Workforce Gaps, Policy, and Future Directions.”

The research shows that there is a shortage of available home healthcare providers with pediatric training to serve children and youth with medical complexities. The research proposes solutions to address payment reform, improve coordination of services, and to provide pediatric home health training through partnerships with child-focused health systems.

The article also proposes using telehealth-enabled opportunities to bridge current workforce gaps and to advance complex home-based care. Telehealth needs to be used to take care of children in the home with complex medical issues, technology needs to be used to effectively link institution-based specialists with home nurses to monitor patient status, manage symptoms, and provide care in real time.

Videoconferencing and remote home monitoring of clinical parameters for respiratory physiology and blood sugar, offer tools to link children’s families, healthcare providers, and home healthcare staff.

Telehealth may also provide a bridge to address workforce shortages by supporting nurses without pediatric experience or by supporting nonclinical aides or extended family caregivers to care for more patients at home to connect virtually with pediatric specialists and home health agency nursing supervisors.

However, Dr Foster also thinks that as telehealth increasingly includes remote patient monitoring, the home healthcare workforce is going to require appropriate training and education to achieve the maximum benefit from the use of telehealth along with other clinical tools.

Other panelists on the “High Quality Care Teams” panel discussion included Karen Donelan, Senior Scientist Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital and Associate Professor of Medicine at the Harvard Medical School, discussing the article “Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians.”

The article points out that services provided to frail older adults need to be integrated with Registered Nurses (RN) and social workers to provide medical and social care management. However, even though many new care models rely on RNs and social workers working together, this work arrangement is rarely used in practices.

Brad Stuart MD, CMO at the “Coalition to Transform Advance Care”, presented information on the article “A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model”. The article describes a team-based intervention providing home-based coordinated care to more than 2,000 seriously ill patients daily in 19 urban suburban or rural counties in California.

Go to for the video of the event.

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