Dr Jo Scott-Jones, Pinnacle’s Medical Director, discusses proactive care

dr-jo-scott-jonesIn a recent BMJ article, Richard Smith highlighted the gap that exists for “high need, high cost” patients between what they require of the health system and what is provided for them.

This group of patients represents a mixed population, but in general is over 65, have multiple morbidities, are functionally compromised, as well as having behavioural problems, often poor and near the end of life. The Commonwealth Fund’s David Blumenthal in a lecture to the Institute of Global Health Innovation discussed how best to respond to this group of people who in the US represent 5% of patients but who account for 49% of the costs of the health system.More importantly, still we know these patients are the people who most need the care we can offer and the wrap around services of the wider primary care team.

Blumenthal highlighted the problem that health systems have in supporting the “microsystems” that GP clinics and primary care providers develop to address the needs of these patients, often the system adds in bureaucracy to try and manage systems that have evolved in response to patient’s needs, and in doing so rather than creating scale and enabling care, the system becomes more pressured.

The Health Care Home model provides a supported model of care that enables clinicians to better care for patients in this group, but it requires new ways of doing things.

Pinnacle HCH_graphic_CMYKHelen Parker of Pinnacle Midlands Health Network’s Health Care Home team says “the first thing we do is identify the high needs patients within each practice population using a stratification process we have developed, so everyone knows who they are.”

They then apply a “year of care” which involves proactive clinical and case management, provided with the support of a named care coordinator.

She says “evidence suggests this will reduce the cost to the system and improve patients’ experience.”

Pinnacle funds a contribution towards an hour long appointment to plan the care but more importantly is working with practices to redesign what the workforce does to create the capacity to do this work without needing more practice nurses and doctors. “We use medical care assistants and new patient flow processes to make sure we have time to do the broader care these patients need.”

But it’s not easy, in just one example of the challenge, Helen says recently “I was talking to some nurses in a practice who said they had no time to do this degree of proactive management or care coordination, and while working through their weekly caseload it became clear that around 10 hours per week was spent by nurses in this large practice just on blood pressure checks. There are easy solutions to this using kiosk technology or by using Medical Care Assistants , but the nurses said they built up their patient relationships doing blood pressure checks and wouldn’t ever want to let them go.”

“We need to be bolder if we are going to cope with the rising tide of high-needs patients in our community.”