February 12, 2015 katharina.janus

New on the Health Affairs Blog: Insights on how to create a network for the chronically ill

This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

The Challenges Of Developing A Sustainable Network For The Care Of The Chronically Ill
By Ronald Kuerbitz and Benjamin Kornitzer


Health care systems the world over are searching for new organizational models to deliver better clinical outcomes, improved customer satisfaction, and lower costs. In any such systems, quality will no longer be the sole province of clinicians and the responsibility for cost containment will no longer fall solely on payors. Increasingly, clinical care and social service providers, patients, and payors alike have a role to play in achieving the best clinical outcomes for patients and the best economic outcomes for the system as a whole, signifying a value based health delivery system.

As primary and acute care networks embark on this move from volume to value, the special needs of chronic populations, those that comprise 45 percent of domestic health care spending — or $1.2 trillion annually, can easily be lost and, with them, the ability to address a very significant gap between quality outcomes and cost controls.

We assert this failure is largely due to underlying system designs, focused on the healthy primary care population and episodic care for the large population of patients with acute needs. Systems designed to serve these populations do not lend themselves to optimizing care for the patient with multiple chronic conditions. Specifically, we suggest that in order to develop a sustainable care network for the polychronic patient, subsystems with the following attributes should be developed.

  • Treatment goals: The goal of chronic care is not finding a cure. Rather, it is helping patients manage their condition so they can avoid crises and manage flare-ups.
  • Physician and patient relationship: The imperative for a true partnership between the chronically ill patient and clinician demands a profoundly different attitude and approach than the acute setting. In other words, while the clinician is often called on to do something to an acute patient (i.e. prescribe a medication, perform surgery), he or she must instead find the best way to work with the chronic patient and his or her support network.
  • Evidence-based care: While the increased focus on checklists is admirable for the acute setting—thus ensuring that physicians deliver the right care to the right patient at the right time—this approach in isolation fails to address the complex nature of the chronically ill patient. We believe that chronic patient care networks need to provide sufficient flexibility to actively engage patients, while also ensuring appropriate standardization of certain high value areas. Networks should develop adaptive learning systems that embrace disease-specific data sets and predictive models to identify leading indicators, identify suboptimal outliers, and develop high value standardization tools, and apply those tools with an individualized patient focus.
  • Multidisciplinary interventions: The needs of the polychronic patient are extremely complex and go well beyond the traditional definition of medical care today. We believe a provider network designed to address the social, functional, pharmaceutical, and psychosocial needs of the patient, in addition to traditional medical care, is required.
  • Longitudinal data: A hallmark of the polychronic patient is frequent touch points within the health care system, from laboratory testing, to hospitalization, and use of specialists. Each of these points of engagement generate data, which can be harnessed to identify leading indicators and transform episodic and reactive care into prevention and management.
  • Measure of success: While speed, completeness of recovery, or both are frequently cited measures of success, these are not appropriate for the polychronic patient and their providers.

With the challenges of polychronic patients in mind, providers could consider helping patients navigate the health care system more effectively by coordinating regional health systems with chronic care subsystems, and providing case managers, for example, who are trained to assist the patient, provider, and support network with functional, social, and medical needs.

Many renal patients, for example, face a treacherous transition from chronic kidney disease to renal replacement therapy carries with it some of the highest mortality rates known in medicine today. According to the United States Renal Data System’s 2014 Annual Data Report, all-cause mortality reaches 421 deaths per thousand for patients in the second month of hemodialysis.

It does not have to be this way, however. By deploying case managers to help patients schedule times with vascular surgeons and other specialists and by providing patients and families’ education on dialysis modality options, and diet and lifestyle recommendations, our data shows that hospital admissions and hospital days can be reduced by 25 and 40 percent, respectively, and mortality by 36 percent.

In short, innovation in the delivery of care for chronic patients is critical to the sustainability of our health care system, and this provides the best hope for improving outcomes for these patients.