Primary Care Complexity

1. Primary Care Complexity Dartmouth Medical School Dept. of Community & Family Medicine Faculty Development Grant Program Kevin Shannon, MD, MPH Karen Schifferdecker, PhD Isabel Weatherdon

2. Objectives Understand basic complexity theory Understand 4-Quadrant Model Consider the complexities of depressed geriatric patients Discuss complexity in your practice Discuss your resources for managing complexity

3. Traditional Biomedical Model Reductionistic � focusing on specific organ systems or single diseases Linear in thinking Pt.A + Dz.B ? Path. Outcome C Path. Outcome C + test ? detect Dz.B DzState B + therapy D ? healthy Pt.A This process is repeated again and again with each patient The PCP then interacts with the health system to treat the discrete diseases�

4. REDUCTIONISTIC REALITY:

5. The Problem of Complexity The Reality is: human beings create �Complex Adaptive Systems� � not predictable machines�when you do something for a patient, they will often do something unexpected in response �providers and health systems must address more complex & undifferentiated care issues that don�t fall neatly into the traditional linear approach � because we are caring for individual human beings�

6. Complex Health Issues Chronic overlapping diseases � where outcomes depend not just on the individual conditions, but on the relationships between diseases and pt�s experiences of them Pt�s perceptions of illness may depend more on personal/cultural beliefs than objective scientific information So, we need to create/organize health-related plans for complex patients

7. When traditional medical model doesn�t fit If patient very complex, then the dynamics of their problems are: - neglected, or - noted but �dissected� into multiple discrete problems (ignoring the interrelationships), or - the complexities are addressed, but laboriously and inefficiently

9. Complexity Model Recognizes health involves a broader spectrum of dynamic health care needs occurring to different degrees during life Complexity increases as disease burden, chronicity, technical/organizational aspects, psychosocial aspects grow. Not just Dz mgt, but recognition and treatment of the larger system of processes and relationships involved in the multiple, interrelating issues of human health

10. The Patient � Health Systems Interface (PHI)

11. A change of paradigm? Not just adding more disease-specific �channels� to find resources and meet needs, Rather, new �channels� to resources must be created in a practice to find the information and resources needed for complex patients -- and these channels must be left �open� longitudinally, functioning in parallel with disease-specific channels

12. A New Way to Plan for Complexity How do we prepare our practices to handle complex patients? By: Creating new categories, not based on diseases, but on complexity, Analyze out practices according to these categories, (do chart review) Organize our resources to meet the needs of patients in each category

13. The 4-Quadrant Model

14. The 4-Quadrant Model

15. Quadrant 1:Acute/Straightforward Problems that fit the linear biomedical model well � clear diagnosis & treatment Little dynamic fluctuation, so the Dx & Tx remain stable until resolution protocols work well; less meaning issues Predictable information & resource needs Minor procedures/UTIs/URIs/OM �

16. The 4-Quadrant Model

17. Quadrant 2:Acute/Complicated Increasing technical & organiz. complexity But time-limited, so less associated with complexity of relationships and meanings Less uncertainty than chronic E-B protocols work only fairly well, b/c sometimes several simultaneous Dx Info & resource needs are intense Acute asthma/CP/Abd. Pain/dehydration

18. The 4-Quadrant Model

19. Quadrant 3:Chronic/Straightforward Each problem medically straightforward, but chronicity brings historical dynamic Identity /meaning bound up in chronic Dz Need info. channels that aid longitudinal monitoring, info. gathering, & self-mgt PHI needs to support building richer relationships to address values, meanings DM/HTN/chol./stable asthma/prevention Wagner model works well (�Planned Care�)

20. The 4-Quadrant Model

21. Quadrant 4:Chronic/Complex Most challenging � increasing number & severity of problems � less certainty Meaning, history, values are at issue Need interdisciplinary approaches Monitoring more important PHI must be flexible � several channels functioning in parallel Frail geriatrics/psych./multiple,severe prob

22. Geriatrics � Matilda B.: 82 yo female, husband died one year ago Depressed, failing at home alone Lost several IADLs, still has ADLs Becoming forgetful, children worried:safety NIDDM, HTN, Chol, COPD (O2-depend.) Fixed income: meds are too expensive The one local daughter cannot handle pt�s needs alone anymore (calls to tell you)

23. How would you care for her? Is your PHI complexity-friendly? How do you feel about the care you provide for such patients?

24. Discuss your �microsystem� for Complex Patients (Quadrant 4) Front office staff Nursing Providers Finance/Admin. Social work (?) Lab (?) Information systems/channels Accessing outside resources Team meetings

25. Help us help you� We are creating a: �Complex Patient Handbook� �to meet the needs of our grant practices for caring for complex patients �a compendium of helpful resources �a database that will be accessible via the grant web site, but also able to create hard copies for individual sites