By many estimates, only 5 percent of U.S. patients are high-need, high-cost, yet they account for about 50 percent of healthcare spending. New research published in the New England Journal of Medicine finds it's necessary to understand the needs of this patient cohort, identify drivers of their utilization, and implement solutions to improve their clinical outcomes while reducing their costs.
High-need, high-cost patients often have multiple chronic conditions, complex psychosocial needs, and limited ability to perform activities of daily living. Care delivery solutions, including care management, telemedicine, and home health visits, have had mixed levels of success for various outcome measures.
Some of those include system-centric measures such as total cost of services and utilization of secondary care (emergency department use and inpatient hospitalization) as well as patient-centered ones such as self-assessed health status.
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A possible explanation for the variable success could be that many solutions are designed primarily by health system administrators, not the patient "customers" who best understand their own needs.
To bring the voice of the patient to the forefront, qualitative researchers from Weill Cornell Medicine and University of Florida led several focus group discussions with 21 high-need, high-cost patients and three primary caregivers, representing an urban healthcare system in New York City and a second one in Gainesville, Florida.
Participants -- a racially diverse group ranging in age from 23 to 80 -- identified five solutions they felt would help prevent overuse of the ED and other hospital services for symptoms and/or conditions that can be well-managed at primary care clinics.
The five solutions include care management; readily available at-home physical therapy and nursing services; home delivery of prescription medication and easier refills; telemedicine; and more after-hours clinics.
Patients saw immense benefit in many of these solutions. For care management in particular, patients appreciated help with appointment scheduling and reminders. Patients perceived care managers as trustworthy partners in their day-to-day healthcare -- available to talk to and answer questions if they felt anxious.
While the jury is still out on the return on investment of care management in terms of utilization and outcomes, the patients in the focus group were convinced of its benefits.
Patients also described how they sometimes are unable to pick up their prescriptions for extended periods of time and appreciated the option of having medications delivered to their home to avoid any exacerbation of their illnesses.
Some also felt that for some medications, a larger supply per refill cycle would be optimal. Several pharmacy groups are piloting automatic monthly refills and home delivery of prescription medications, and these services should be more widespread and better publicized, the authors said.
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Some recognized the potential benefit of telemedicine for regular appointments or non-emergent conditions. They felt that communicating with a medical provider who was personable and familiar with their symptoms could reduce the anxiety of time-sensitive, unanswered questions that often result in an ED visit.
Others, however, expressed uncertainty about the use of telemedicine for conditions such as cardiovascular disease, saying that they wouldn't take a chance with remote care in case "things go wrong" and would rather seek care in a doctor's office or ED.
Many patients, especially those who work 9 to 5 or whose personal caregivers are unavailable during normal business hours, felt that increasing the number of after-hours clinics at convenient locations was crucial to reducing their reliance on the ED. However, patients felt that after-hours clinics would be underutilized if transportation options were limited, reinforcing the need for convenient locations.
Almost all of these solutions are being piloted in various settings. To enhance the success of care delivery models, the authors said healthcare systems should consider directing more resources to some of these existing solutions that patients believe could lower utilization of secondary care for chronic disease management.
Decreasing utilization has long been a goal among health leaders. A pilot study by investigators at Brigham and Women's Hospital in February 2018 reimagined the best place to care for select, acutely ill adults. The project posed the question: What if, instead of being admitted and receiving care at a hospital, a patient could be cared for at home, and monitored using cutting-edge technology?
The results, according to the study, would be decreased costs and utilization, as well as improved physical activity for patients.