Resource Planning for Patient-centered, Collaborative Care

Care coordination for patients with complex health profiles in inpatient and outpatient settings

Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.

The role of home-based information and communications technology interventions in chronic disease management: a systematic literature review

This article presents a systematic literature review done to evaluate the feasibility and benefits of home-based information and communications technology enabled interventions for chronic disease management, with emphasis on their impact on health outcomes and costs. Relevant articles were retrieved from PubMed and evaluated using quality worksheets with pre-identified inclusion and exclusion criteria. Of the 256 articles retrieved, 27 were found to concord with the study criteria. Evaluation of the identified articles was conducted irrespective of study design, type of home-based intervention or chronic disease involved. The review demonstrates that HBIs applied to chronic disease management improve functional and cognitive patient outcomes and reduce healthcare spending. However, further research is needed to assess benefit in terms of evidence-based outcome indicators (that can provide a basis for meta-analysis), to confirm sustainable cost benefits, and to systematically collect data on physician satisfaction with patient management.

Therapists' Perceptions of how Teamwork Influences Client-Centred Practice

This qualitative study adds to the client-centred literature by focusing on occupational therapists' experience of working on teams that support clients with a severe and persistent mental illness from a client-centred perspective. The paper reports on the second category of data relating to a previously published paper, which replicated the work of Sumsion (2004).

Interviews were conducted with 12 therapists to capture their experience and interpretation of this approach to practice. The multiphased analysis included template analysis and open coding. It resulted in the creation of the category of meaningful goals, which addressed the work done to ensure that the goals towards which everyone was working were meaningful for the client. The facilitators related to these goals included team cohesion, the structure of the system and family collaboration and support. The challenges were differing perspectives and paradigms, competitive frameworks and time.

This study identified the unique contribution that families provided to a client-centred approach. Overall, the study makes a significant contribution to the literature and to therapists' understanding of the factors that influence the therapist's ability to facilitate client-centred practice.

Multiple Health Problems in Elderly People: Adapting what is known

With ever increasing pressure on doctors’ time, Iona Heath (doi: 10.1136/bmj.39532.671319.94) wonders whether primary care really meets the needs of elderly people at all, while John Wasson suggests ways for doctors to improve the care of older patients that don’t require extra resources or staffing

Postscript

In this report, we compare healthcare processes for patients with low (n = 7467) and adequate financial status (n = 43,701) after adjustment for age, gender, burden of illness, and health behaviors. Patients with low financial status were 10% to 30% less likely to report good service and collaborative care; they report that markers of disease management and prevention were 7% to 18% below the levels of patients with adequate income. From the patient perspective, these results confirm that inadequate financial status has a broad and adverse influence on health and healthcare. Technology for patient-centered, collaborative care alone will not remedy the problem of health disparity.

The Emergence of Ideal Micro Practices for Patient-centered, Collaborative Care

Ideal Micro Practices are capable of delivering patient-centered collaborative care. With respect to comparable adult patients in "usual" care settings, twice as many patients who use Ideal Micro Practices report they receive care that is "exactly what they want and need exactly when and how they want and need it" (68% vs 35%). Compared to usual care, these very small, low-overhead practices are more likely to have patients report very high levels of continuity (98% vs 88%), efficiency (95% vs 73%), and access (72% vs 53%). Patient ratings of very good information (83% vs 67%) and clinician awareness of pain or emotional problem are also higher (87% vs 69%). However, only a slim majority of patients using Ideal Micro Practices report that they are confident in their ability to manage and control their health problems or concerns. Ideal Micro Practices are sharing new tools and approaches to better understand their patients' needs and increase patients' confidence in their ability to manage conditions. In addition, these practices are working collaboratively to standardize their approaches and make the essential elements of Ideal Micro Practice replicable.