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Forces Influencing the Care of Complex Patients: a Framework

OVERVIEW. Sources of ComplexityExamples of non-biological sourcesThe ?spider web" frameworkBarriers to managing complexity. Patient Complexity: not only Comorbidity. Sources of patient complexityBiologicalSocioeconomicCulturalEnvironmentalBehavioral Health care system must address ALL thes

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Forces Influencing the Care of Complex Patients: a Framework

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    1. Forces Influencing the Care of Complex Patients: a Framework Catarina Kiefe, MD, PhD with Monika Safford, MD and Jeroan Allison, MD, MscEpi Deep South Center on Effectiveness: a VA HSR&D REAP Center for Outcomes and Effectiveness Research and Education University of Alabama at Birmingham June 4, 2007

    2. OVERVIEW Sources of Complexity Examples of non-biological sources The “spider web” framework Barriers to managing complexity

    3. Patient Complexity: not only Comorbidity Sources of patient complexity Biological Socioeconomic Cultural Environmental Behavioral Health care system must address ALL these sources to maximize health

    4. Biological Complexity High patient variability in Multiple comorbidity Presentation of disease Clinical course of disease/response to treatment Existing evidence based guidelines generally do not handle this variability well Because we lack the evidence…

    5. Socioeconomic Complexity: the Homeless Example Kertesz S, personal communication, 2007 ~ 400,000 Veterans experience homelessness each year VHA spends ~ $1 billion/year serving homeless ~ $225 million in specific homeless services Homeless (compared to housed) veterans are hospitalized younger (by 10-18 yrs for medical/surgical dxs) more for psychiatric and substance abuse diagnoses (80% vs. 29%) Adams J, J Health Care Poor Underserved 2007 With more recurrences of lower extremity cellulitis Lewis SD, Am J Med Sci 2006 More frequently when HIV + Gordon AJ, Med Care 2006

    6. How does VA address Homeless Complexity? Examples Housing & Mental Health programs predominate e.g. HUD-VASH: RCT of housing vouchers vs no vouchers embedded in 19-site roll-out of supported housing (1992) Better housing & addiction outcomes Rosenheck. R, Arch Gen Psych 2003; Cheng, J Nerv Ment Dis 2007 VA tends to couch homelessness as a Mental Health Service, BUT Among ~27k mentally ill in HCHV only 42% rec’d Primary Care over 6 mos Desai, M Med Care 2003 Homeless Veterans appear to have medical needs met no more frequently or even less so than homeless non-veterans. Desai, Gen Hosp Psychiatry 2005 & Kushel, JAMA 2001

    7. Other Examples of Robust VA Homeless Research Northeastern Program Evaluation Center ~90 peer reviewed papers since 1988 Eg: In prospective f/u (n= 6199 homeless), social security cash benefits not associated with increased substance abuse Rosen M, HSR 2006 Pilot of peer-assisted case management of mentally ill veterans Weissman EM, Community Ment Health J 2005

    8. Cultural Complexity: an Example McEachrane-Gross, BMC Complement Alt Med 2006 27 % of 264 Veterans with cancer/chronic pain reported CAM use: herbs, dietary supplements, chiropractice, massage, acupuncture, homeopathy CAM use positively associated with belief that lifestyle contributes to illness (also education, income, non-VA insurance) 76% would use CAM if offered in VA

    9. A vector model of complexity Safford, Allison, Kiefe, JGIM, under review

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