Delivering Complex Care: Designing for Patients and Physicians
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and Albert W. Wu, MD
Department of Medicine, General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
The management of high-utilizing patients is an area of active research with broad implications for the healthcare system. There are significant operational challenges to designing primary care models for these medically complex, high-needs patients. Although it is crucial to provide a high degree of continuity of care for this population, managing a cohort of these patients can lead to provider over-work and attrition. This may be magnified by the lack of training dedicated to addressing the unique care needs of these patients. While academic medical centers would seem well suited to care for individuals with multimorbidity needing intensive and specialized treatment, primary care providers in this setting need additional support to be clinically available for patients while pursuing scholarship and teaching. Formally recognizing intensive outpatient care as a specialty within internal medicine would help overcome some of these challenges. This would require a committed effort to high-level systems changes including a new focus on graduate medical education, the creation of division-level infrastructure within academic departments of medicine, and realistic levels of financial support to make this a viable career path. J Gen Intern Med DOI: 10.1007/s11606-020-06212-3 © Society of General Internal Medicine 2020
“high utilizers” are complex patients who use I an healthcare, disproportionate amount of health care relative to their peers. The burden of repeated episodes of illness and treatment falls heavily on these people. Much of this cycle seems avoidable, and in the last decade, attempts to improve care for these patients have gained momentum.1, 2 The most promising interventions have involved rethinking the roles of providers and the practices that care for these patients.3–5 Complex patients benefit most from a high degree of continuity of care and attention from their primary care providers.6–13 However, maximizing provider accessibility to match the needs of this population places heavy demands on the time and availability on those clinicians. So, to do it, the Prior Presentations None. Received April 13, 2020 Accepted September 3, 2020
medical community must grapple with what can or should be expected from the modern physician. In this commentary, we discuss the challenges in designing practice models that optimize care for high-utilizing patients. When designing a care model for complex patients, one of the primary questions is who will deliver that care. One requirement is that the model has appropriate structure and support to maintain a high degree of patient-provider continuity. This produces physicians who are intimately familiar with their patients, aware of their social and medical challenges, and up to date with their past and current care. Greater continuity of care is associated with decreased hospitalization, better patient care metrics, and lower costs.13 T
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