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Improving care for the frailest, elderly patients

6193352974_7f7e6ff120_zCaring for the oldest, frailest patients isn't easy. They can bounce in and out of the hospital with less-than-ideal outcomes. They see handfuls of specialists, who each look at just a slice of the patient: their heart, or eyes, or knees.

Arnold Milstein, MD, director of Stanford's Clinical Excellence Research Center, laid out the problem for me in a recent email:

Care-delivery methods are in a constant state of evolution as poorly met patient needs become widely apparent, though the pace quickened after the enactment of the Affordable Care Act.

As a cumulative tsunami of NIH-catalyzed new medical treatments triggered narrower and narrower medical specialization, adverse health and financial consequences from coordination failures grew especially severe for medically fragile patients with multiple conditions.

With Harvard MD-MBA student Brian Powers and Sachin Jain, MD, a consulting professor of medicine at Stanford, Milstein presents two potential fixes in a recent study in the Journal of the American Medical Association.

One model, called the comprehensive care model, is based on a University of Chicago Health System program that matches Medicare patients with one hospitalization in the previous year with a "comprehensive care physician" who leads both inpatient and outpatient team-based care. These physicians meet with outpatients in clinics in the morning and are paged when one of their assigned patients is admitted to the emergency room, where they can help direct care and potentially avoid unnecessary hospitalizations.

A second model, called the "extensivist" approach, stems from a Southern California program originated by CareMore Health System, an Anthem subsidiary. Patients in the top 5 percent of predicted health-care spending are identified and assigned to a physician, called an "extensivist," who leads a team of nurse practitioners, case managers, medical assistants and a social worker and nutritionist to care for the patient both in and out of the hospital.

"The extensivist and CCP models may appear to be a return to a nostalgic, prehospitalist era when primary care physicians cared for patients across sites of care," the researchers write.

The verdict on the success of these models is still out, the researchers write, but these two alternatives, as well as Stanford Coordinated Care for medically fragile patients of all ages, "represent especially thoughtful solutions," Milstein told me.

Previously: Health-care policy expert Arnold Milstein weighs in on Medicare's plan to prioritize "value over volume", Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence and Stanford Coordinated Care: A team approach to taming chronic illness
Photo by Abdulsalam Haykal

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