For patients with multiple morbidities, multidisciplinary care team meetings can develop valuable approaches to effective treatment.
Having complex care conferences in the primary care setting for high-risk patients can boost care coordination and collaboration, a clinical leader from Providence Health and Services said at this week's IHI National Forum.
High-risk patients with multiple morbidities pose daunting challenges for health systems, hospitals, and physician practices, which often struggle to adequately manage patients with multiple health conditions, leading to high mortality rates, increased costs, and other negative outcomes.
At Providence, complex care conferences at primary care practices are fostering a team-based approach to treatment, Vanessa Casillas, PsyD, director of psychology at the Renton, Washington-based health system, told HealthLeaders after her forum presentation.
"One of the top reasons for complex care conferences is that the more intense the needs a patient has the more people who tend to be involved in the care. This is about coordinating and collaborating," she said.
The primary result of a complex care conference is a care plan that identifies two to four salient items such as medication adherence for care team members to focus upon.
"Care conferences help determine what we should be doing. We may decide to let some goals fall away in the short-term because they don't make sense. We want to get the patient engaged without overwhelming them," Casillas said.
During her forum presentation, she said there are four essential elements of effective complex care conferences.
1. Stratifying patient risk
To determine which patients could benefit from complex care conferences, Providence risk stratifies patients into four cohorts: very intense, intense, moderate, and low.
- Providence developed its own computerized risk stratification algorithm that includes emergency room visits, hospital admissions, high-risk medications, and behavioral health diagnoses.
- Care teams validate the computerized risk stratification. For example, some patients who are categorized as very intense risk could be shifted to a lower-risk tier if their comorbidities are managed well.
2. Preparing for complex care conferences
Casillas says "pre-work" for a conference helps identify which very intense risk patients are appropriate for a team meeting and ensures meaningful use of time.
- Advance preparation should include a determination of why a conference would likely generate a valuable discussion.
- Pre-work should include determining a patient's status and whether the patient has shared treatment goals with staff.
- Barriers to care such as social determinants of health, physical barriers, and financial barriers should be identified.
- The patient's support system should be evaluated to see whether there are people actively involved in their day-to-day life who could help the care team.
3. Conducting complex care conferences
Anyone who is actively involved in a patient's care can participate in a conference, including primary care physicians, embedded case managers, embedded behavioral health providers, embedded pharmacists, nurses, and clinic managers. Offsite healthcare staff such as ER physicians can attend in person or via a teleconference connection.
- The conference should have a facilitator, who does not necessarily have to be a primary care physician. In most cases, the best facilitator is the person who knows the patient best.
- The conference should be documented, including a list of attendees.
- The electronic health record should be available to review if necessary.
- Every discipline at the conference adds value, so each person in attendance should have an opportunity to contribute to the discussion.
- Action items should be identified and assigned to care team members.
4. Following up after complex care conferences
After a conference is held, follow-up work is crucial to ensure time has been well spent and the patient's care plan is executed and widely distributed.
- Document the care plan in the patient's chart.
- Communicate the care plan to all care team members, particularly staff who were unable to attend the conference.
- Distribute the care plan to all related care settings such as emergency departments.
- Schedule a visit for the patient to review the care plan, with adequate time for the patient to ask questions.
- Develop contingencies in case the care is unsuccessful or unanticipated barriers to care are encountered.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
High-risk patients benefit from care teams that are coordinated and collaborative.
Risk stratification helps identify patients who are most appropriate for complex care conferences.
Successful complex care conferences are structured to encourage staff participation and generate a concise care plan.