Communities and their role in improving care for the five-percenters

In our quest toward ‘goldilocks medicine’ we traveled in mid November 2011 to St. Louis Park near Minneapolis, Minnesota. We were invited by city officials and organizations — including Park Nicollet Medical Home Program and Park Nicollet Foundation — convened by Marjorie Herdes and William Stockton from Mobius to discuss new city initiatives.

I shared some new thoughts along with some standard stuff about minimally disruptive medicine.  The new thoughts refer to the role communities can play in reducing the burden of treatment for patients with multiple chronic conditions.

They were particularly impressed by data from Mayo Clinic showing that patients with 3 or more chronic conditions account for 5% of Medicare patients and incur 50% of all healthcare expenditures. These data is similar to that reported several years ago from the MEPS; as opposed to what I would have predicted this 5:50 rule appears to have remained the same for the last 15 years (see this from 1996 and this from 2008). Also, the latest report from the MEPS (2008) identifies 10% of the population now accounting for 60% of all healthcare expenditure. This group is most likely female, poor, of an ethnic or racial minority and with poor self-rated health. Of note, 1% of the population accounts for 25% of healthcare costs!.

Returning to the 5:50 rule – the fact that counting comorbid conditions can identify this group offers an opportunity for targeting folks on the basis of their complexity. The challenges of this 5% include a very large burden of treatment which often exceeds the capacity of patients and of their caregivers and leads to reduced healthcare access and use, and poor self-care, i.e., to bad outcomes.

While the Chronic Care Model and other forms of intensive primary care can enhance the quality of care for patients with chronic conditions, these models have failed to account for the workload-capacity imbalance that often characterizes these patients and leads to waste and poor outcomes through poor treatment fidelity.

What could organized communities do about this?  How could they improve patients’ capacity to face the workload of comorbid chronic disease, improve their health, and bend the cost curve?

Many ideas were considered and discussed, greatly facilitated by the work our colleague Nathan Shippee, a brilliant sociologist, has been advancing to understand the balance of capacity and workload in these ‘five-percenters’.

Nathan Shippee, PhD

Capacity seems to result from marshaling resources in the following domains:

  • Personal: resilience, physical and mental function, quality of life, self-efficacy, literacy, education, values
  • Medical: design of healthcare services, accessibility and outreach, care coordination
  • Financial: transportation, communication, housing, coverage, access
  • Social: emotional, social, and instrumental (practical) support
  • Contextual: neighborhood design, healthy environment and resources, location, safety

Community programs that could provide resources in one or more of these domains could partner with primary care medical homes focused on this population and help enhance their capacity to face the existing (and hopefully shrinking) workload of being a chronic patient.

Turns out that at St. Louis Park there are already many organizations and programs that offer services that could enhance capacity for patients and caregivers. Everyone in the room agreed that the challenge is to make eligible folks aware that these services exist, often at no cost to the beneficiaries.

Of course poor access to help is a hallmark of an overwhelmed patient, one whose workload exceeds their capacity.  Thus a key priority is to work with existing programs to explore how much work does it take to access and use their services and to redesign their offerings to reach out to these folks in a minimally disruptive way.

This innovation – of communities that reach out to patients and caregivers to optimize their treatment burden – may hold an important key in improving population health, enhance the experience of care, and bend the cost curve, probably in that order.  Given that many of the patients are relatively young, the community will benefit not only from lower per capita healthcare costs but also a closer-knit community with its members contributing to its development and well being. And they would help healthcare systems produce better outcomes as they pursue minimally disruptive medicine. Seems like it will take a village.

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