Category: Reflections on MDM

MDM in practice, Reflections on MDM, Views from the frontline of care

Caregivers – overwhelming the silent

To deliver minimally disruptive medicine, it is key to reduce the workload and enhance the capacity of the patient while pursuing patient goals.

Often, the workload is not faced by the patient alone – a caregiver shares the load. Sometimes, the caregiver carries all of it. Caregivers are seldom compensated for their work, they give up a lot, and their health and other needs are poorly addressed.

Some patients with multiple chronic conditions cannot recruit caregivers because they do not look disabled or terribly sick. Without caregivers, these patients cannot face the workload the healthcare system imposes on them.

Thus, caregivers (or their institutional substitutes) are a key component of a system of healthcare delivery for the 5% of patients with multiple conditions that accounts for the majority of healthcare costs.

These series of collated thoughts (a propos of the national caregiver month) regarding caregivers and their role and about some important efforts to support them are important for those who are working to design a healthcare that fits the lives of these patients. Think of the caregivers, honor their role and support them to ensure that their workload does not exceed their capacity.

MDM in practice, Reflections on MDM, Views from the frontline of care

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.

Reflections on MDM, Views from the frontline of care

The role of guidelines in Goldilocks medicine

We have been concerned about the role that guidelines could play in overwhelming patients.  This leads to practitioners considering guidelines as mandates for quality, often overriding patient context and patient values and preferences.  In the case of diabetes, there is a big concern that many guidelines reflect the interests of for profit interests on professional organizations that formulate these guidelines.

Last year, the VA, led by Pogach, Aron, McConnell and others, produced guidelines that take a different approach – a patient-centered one!  To learn more about these guidelines, there is a very interesting discussion in this podcast.

In this podcast, Mark McConnell from the VA in LaCrosse, WI discusses with the Therapeutics Education Collaboration hosts about the evidence in support of diabetes control and how this should be translated in care that fits the life of patients with diabetes.  A valiant effort indeed to reduce the way this care can disrupt people’s lives!

Reflections on MDM

Transferring complexity – how healthcare interrupts life

In working through minimally disruptive medicine, we are uncovering how the healthcare system has been developing habits — I think this is the right term — that essentially transfer complex work from the healthcare system to the patient.

Take appointment scheduling – some back offices have different schedulers for different types of appointments resulting in uncoordinated visits.  A patient with whom we are currently working made more than 30 trips to the clinic, often times for one or two visits each time.  This was particularly problematic because she could not drive.  A family member ended up moving to town to help with this task…her life being disrupted by this “need”.

Take prescription refilling – some insurers do not enable pharmacies to refill prescriptions before a particular date even if this was the day that worked for this patient to ask for the refill.  Some specialists will write their own prescriptions and these will get renewed at different times than those of others.  Thus, the patient is left with multiple prescriptions refilled and renewed by different providers.  One of our patients went to the pharmacy 43 times in a year to refill prescriptions!

Take e-health interventions.  Many of the new technologies require patients to interact with machines and devices, often times in quite extensive ways.  The designers of these technologies have not clearly acknowledged that the purpose of healthcare is to enable patients to pursue their life’s goals and dreams unhindered by health concerns (or by healthcare itself).  Healthcare should get out of the way, not be “the way”.

More to come as we get deeper into ‘Goldilocks’ care.

MDM in practice, Reflections on MDM

Tailoring treatments to patient capacity

In a provocative piece, Slate magazine’s Darshak Sanghavi writes about “tiered medicine” and proposes that clinical protocols be titrated to patient capacity.  This again approaches the notion of “Goldilocks” medicine we spouse in Minimally Disruptive Medicine. We have also discussed the need to have guidelines that appreciate this issue and that perhaps efficacy may need to have a secondary priority, particularly among patients who are overwhelmed with multiple chronic conditions.

MDM in practice, Reflections on MDM

Administrative disruption as a component of treatment burden and as opportunity for minimally disruptive medicine

I had a patient who told me that she was not experiencing any significant burden of treatment from caring for her type 1 diabetes.  A minutes later she went on to tell of a tragicomic experience trying to get an Omnipod insulin pump: calls to diabetes clinician, educator, insurance company, Omnipod rep, plus their administrative assistants, voicemails, faxed forms requests, etc.  This story made me think of this brilliant video by The Altons:

This video of Air Healthcare is based on an article by Jonathan Rauch in The National Journal Magazine here.

Clinicians need to be aware of what happens in their own front offices, back offices, and the administrative challenges patients face with access to them, their medicines, devices, and other components of their care.  These disruptions may lead to poor treatment fidelity and outcomes.  A minimally disruptive medicine approach would apply lean methods from a patient centered perspective to correct this situation.  Thoughts?

MDM in practice, Reflections on MDM, Views from the frontline of care

The patient voice – the need for a minimally disruptive medicine service

We are working as a multidisciplinary team to develop a service offering for patients with multiple chronic conditions that will reduce the burden of treatment while pursuing patient goals in primary care.  We are trying to learn as much as we can from other models such as PACE and Graded care.  We are also learning as much as we can from our colleagues in multiple disciplines and in public health.  And, of course, from our patients.

During an in-depth interview, one of our patients commented to the notion of a MDM service the following

I wouldn’t mind having like the whole team of doctors that I work with being able to sit down with them and look at the whole picture and decide a plan that would work out for all of my illnesses and how maybe I could avoid certain things or certain costs or just help me live better, period.

…I just think the biggest, most important thing in illness is having all the doctors be on the same page and know what is going on with you individually so that they can help you meet your best expectations and your best health.

Hi expectations we will have to satisfy if we are to make a difference to the workload/capacity balance of these patients.  Onwards!!

Reflections on MDM

Prepared Patient Forum blogger resonates with Minimally Disruptive Medicine

Jessie Gruman resonated with “patient John” and the concept of minimally disruptive medicine.  In this post, Gruman says:

There are few of us whose lives are not so full of responsibilities that we would not benefit from our clinicians’ recognition of the level of effort required of us when they recommend complicated changes to our daily routine.   At a time when patient-centeredness in health care is a concern of policy makers and clinicians alike, Montori’s approach increases the likelihood that we will be able to act on our own behalf.  In seeking to mitigate the treatment burden by recognizing both the demands of the treatment and the context in which each patient must meet those demands, this care is consistent with the Institute of Medicine’s definition of patient centered…

Read her whole post here

Papers and presentations, Reflections on MDM

JAMA commentary attacks the notion of clinical inertia

I have discussed how nonadherence to therapy could be conceptualized as nonviolent resistance to medicine’s push to overdiagnosis and overtreatment, particularly in patients with multiple chronic conditions.

JAMA has published an important commentary by which the author’s essentially propose that what some have conceptualized as clinical inertia may be instead interpreted as nonviolent resistance of clinicians to healthcare push for more healthcare on patients. The authors say:

…clinical inertia may be a clinical safeguard for the drug-intensive style of medicine fueled by the current medical literature.”

Minimally disruptive medicine, thus, represents a solution, an assertive one, for both patients and clinicians that needs to overcome corruption of both the literature and the practice.