Building Models of Care for Complex Patients

The US healthcare system can be difficult to change due to its complexity, but caring for complex patients means creating dynamic systems that are driven by patient needs.

During the first plenary session of Putting Care at the Center, the inaugural conference of The National Center for Complex Health and Social Needs, held December 7-9 in Philadelphia, Pennsylvania, panelists discussed building new models to care for high-need, high-cost patients.

Sam Tsemberis, PhD, executive director of Pathways to Housing, outlined how his organization had to redesign the existing system to help patients with medical or psychiatric conditions who were also homeless.

At the time, the system of care in New York did not allow people to enter housing programs unless they treated their clinical conditions first. Pathways to Housing created the Housing First model after talking to the population.

“They told us, ‘Listen, I don’t need the treatment, I need a place to live,'” Tsemberis said. “We redesigned something that was based on people’s most basic needs and priorities.”

For many of the panelists, these models need to be able to care for patients from the very beginning.

“There’s just no doubt that the roots of the challenges that our population faces are in childhood,” Toyin Ajayi, MD, MPhil, chief medical officer of Commonwealth Care Alliance, said. “There are traumas associated with growing up low income, with being disenfranchised, with having poor access to health, education, to housing, to social supports. It absolutely starts at the very, very beginning.”

David Olds, PhD, professor of pediatrics at the University of Colorado School of Medicine, learned that lesson when he worked in the inner city of Baltimore, Maryland. Many of the children he worked with had issues from being exposed to substances in the womb or being abused. “I realized it was too late … and that we needed to start earlier, and pregnancy seemed like a very reasonable point to begin.”

As a result, he developed the Nurse-Family Partnership, which focuses on helping women improve the outcomes of pregnancy through the use of nurses.

The panelists also discussed the importance of the having the right workforce to care for these complex patients.

“We need the kind of people who don’t look at a barrier and say, ‘Now, I can’t do this,’” Parinda Khatri, PhD, chief clinical officer of Cherokee Health Systems, said. “We want people who say ‘I can do that.’” Maybe they don’t know how yet, she added, but they will figure it out.

The people who shine are those who are stubborn, strong willed, and who have a level of courage to deal with whatever happens, Khatri said. That means hiring a person not necessarily for the background they have.

“The shorthand way we talk about the right person for this work … is we hire for value because we know we can train skills,” Tsemberis said in agreement.

The type of work needed to care for complex patients also means an attitudinal change among physicians. For the longest time, doctors have viewed themselves as the center of the care universe, leaving the object of the activity—the patient—an “inert part of the equation,” Ajayi explained.

The creation of a new model of providing care that shifts the way practitioners view their role has been slow, she added.

“Even though we preside over 15 minutes of interaction with a patient, that is probably the least important 15 minutes of their life relative to all the things that happen to them. And we have to be humbled by that,” Ajayi said to applause from the audience.

However, the barrier of disseminating innovative models of caring for complex patients remains. Ajayi likened the audience at the meeting to a Tesla convention: they are breaking barriers. However, they have to become more like a Toyota convention: a standard.

“How do we move these very radical and unique approaches into something that allows us to take it mainstream?” she asked.

One of the key ways is to have meaningful data or published results that show the program works, Tsemberis said. Unfortunately, sometimes when models scale or move into the mainstream, the model doesn’t stay intact and it can drift and become something different, he said. It becomes necessary to fight to keep the program intact.

Khatri and Olds echoed that sentiment. Olds recommended that people building these models know what they want to accomplish and not give up on that clarity.

“Keep your eye on your mission or goal and don’t let yourself be distracted or pulled by the obstacles,” Khatri said. “It’s easy to get lost.”