The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.
This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.
Because of the above, a JAMA article has got my attention. The article explained the development of two models of services provision designed for patients requiring complex management. One of the experiences, Comprehensive Care Model (CCM) is from the University of Chicago Health System, and the other, Extensive Model, is from CareMore Health System of California. What stands out from the two proposals, with small peculiarities among them, is that they try to solve the lack of coordination of the transfers with an organizational model that offers all the clinical skills to a general practitioner who is responsible, with the help of a multidisciplinary team, to cover the global care of this group of patients, both in the community and in the hospital, such as the social health system. They say that, pending the evaluations, the first impressions are very good.
Coordination is always positive, especially when it seeks to reduce the mismatches of fragmented care practice. Transfer programs, medication conciliation (or deprescription), and individualized plans developed jointly, would be examples of initiatives that bring some light to the environmental disorder, but, these alone fail to prevail over the current model of fragmented practice.
The limitations of integration
The integration of services is a big advance. The problem, however, arises when more complex patients need services that are not integrated into the model. To give two examples: the integration of Torbay services does not include hospitals in the territory or, on the contrary, the integration of "Hospital de Vic" services has been done at hospital and long-term services level but does not involve primary care or community services. Even the majority of integrated health organizations don’t achieve fluidity between the different levels and the different institutions despite being apparently merged.
Generating "extensive" models
Going back to the Chicago and California projects, I think it’s time to consider the opportunity to create multidisciplinary teams (family doctor, geriatrician, advanced practice nurse, social worker, community pharmacist, family worker, etc.) who can assume extensive responsibility for groups of patients with complex health and social needs.
The new model would be based on two competencies that ought to be assumed by the extensive professional team:
a) Management of the overall budget (healthcare and social) of the chosen patients.
b) Extensive care responsibility whether the patients are at home, in the hospital, in the social care or in social residence.
The extensive formula, in short, would be: selection of the most complex and frequent patients, delegation of healthcare and social budgetary competencies to a team of generalist and communitarian mentality and exclusive responsibility for this team with regards to the care activity of these patients.