Care Coordination and Chronic Management: A Specialist's View · 06/06/2014 · Care...

Care Coordination and Chronic Management: A Specialist’s View Karen E. Joynt, MD, MPH Harvard Medical School and Harvard School of Public Health Staff Cardiologist, Boston VA Medical Center June 6, 2014

Disclosures • I am a specialist

Outline • Why and When Specialists?

• Why Not Specialists?

• How Specialists? • Challenges to meaningful co-management

• Communication • Electronic Health Records

• Conclusions and Recommendations

Why Specialists?

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

18–44, 2 or 3

45–64, 2 or 3

≥65, 2 or 3

18–44, 4 or more

45–64, 4 or more

≥65, 4 or more

• High prevalence of multimorbidity

Ward and Schiller, Prev Chron Dis 2013

Why Specialists? • Increasing prevalence of complex disease

Go et al, Circulation 2014

Why Specialists? • More familiarity may mean better care

• Lower mortality rates • Higher use of evidence-based therapies • Heart Failure, Heart Attack, Stroke • Less evidence in outpatient setting

• Higher “quality” care but similar outcomes

• Despite a higher burden of disease in specialist-managed patients

Ansari et al, JACC 2003; Go et al, AJM 1999; Joynt et al, Circ HF 2013; Mitchell et al, Stroke 1996

Why Specialists, Continued

5.5% 7.5%

8.6% 10.9%

11.0% 13.5%

10.9% 12.4%

In-Hospital Mortality 30-Day Mortality One-Year Mortality

Cardiologists General Internists Family Practitioners Other Physicians

Jong et al, Circulation 2003

• Lower mortality for heart failure patients

Why Specialists, Continued

90-Day Mortality Discharge Home

Neurologists General Internists Family Practitioners Combination

Mitchell et al, Stroke 1996

• Lower mortality for stroke patients

When Specialists?

23% 25%

36% 34%

30% 34%

Low risk: <75 y, Charlson<2

Medium risk: <75 y, Charlson ≥2

High risk: ≥75 y, Charlson <2

Very high risk: ≥75 y, Charlson ≥2

Cardiologists General Internists Family Practitioners Other Physicians

Jong et al, Circulation 2003

• Greatest benefit is in highest-risk patients

Why Not Specialists?

$12,095

$8,414 $7,536

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Cost of HF HospitalizationCardiologists General Internists Family Practitioners

Joynt et al, Circulation HF 2013; Mitchell et al, Stroke 1996

• Higher costs with more specialists/capita • Higher costs for HF and stroke

$7,218

$5,972 $5,096

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Cost of Stroke HospitalizationNeurologists General Internists Family Practitioners

How Specialists? • Gatekeeping

• Prevent specialty visits at all costs

• Consultation • Obtain limited specialist input

• Shared management • Co-manage multiple conditions, share ideas

• Specialist management • Assume all aspects of care for patient

How Specialists? • Gatekeeping

• Healthy outpatient with occasional needs

• Consultation • Patient with complex organ-system disease

• Shared management • Patient with multiple chronic conditions

• Specialist management • Patient with rare needs (ESRD, VADs, TxP)

Barriers: Communication • The typical primary care physician has 229

(interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician.

Pham et al, Annals 2009

Barriers: Communication

Primary Care

Physician

Specialist Specialist

Specialist

Pham et al, NEJM 2010

Electronic Health Records

Hsiao et al, Health Affairs 2013

EHRs: Specialty Care

Patel et al, JGIM 2013

Patient

Specialist

Primary Care

What is the Right Model?

• Care coordinator linked directly to patient

Patient

Specialist

Primary Care

Care Coordinator

• Care coordinator linked directly to patient

Primary Care

Specialist

• Care coordinator centered with PCP

Primary Care

Specialist

Care Coordinator

• Care coordinator centered with PCP

Primary Care

Specialist

Primary Care

• Care coordinators linked to specialists

Primary Care

Specialist

Primary Care

Care Coordinator

Primary Care

Specialist

Primary Care

Care Coordinator

• Care coordinators part of group practices

Medicare Patient

Primary care

physician Specialist

Specialist

Specialist Primary

care physician

Specialist

Medicare Patient

Primary care

Specialist

Specialist Primary

care physician

Specialist

Specialist Care

Coordinator

Medicare Patient

Primary care

Specialist

Specialist Primary

care physician

Specialist

Specialist Care

Coordinator

Conclusions • The prevalence of complex patients is high

and rising • Specialists are an important part of the

health care team • Can improve outcomes for selected patients

• We don’t know how care should be shared • Likely many models, depending on needs

• Major barriers are communication and lack of “tradition” and clear roles

Recommendations • A team needs to form around the patient

• Best centered with lead decisionmaker

• We need shared information • Electronic health records, personal records

• More evidence should be generated • How should we organize the system? • Local laboratories • Learning health care systems

Thank You! • Questions?

• Contact me: kjoynt@hsph.harvard.edu

Care Coordination and Chronic Management: A Specialist's View · 06/06/2014 · Care...

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