An Eloquent Argument For Coordinated Care

Jane E. Brody’s piece for this week’s Health Section of The New York Times — “Tackling Care as Chronic Ailments Pile Up” – speaks directly to two of the central concerns of The Graying of AIDS: the need for better communication between patients and their doctors, and the need for coordinated care (including increased communication between care providers) to better address the many challenges confronting people living with multiple chronic conditions.

Citing a December 2010 report released by the U.S. Department of Health and Human Services, Brody argues that “[a]nyone seriously interested in improving the health of Americans and reducing the costs of health care must be willing to tackle a growing and underappreciated problem: the vast number of patients with more than one chronic illness.” (For the purposes of the report, chronic conditions are defined as “conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living.” Like many of the individuals profiled in The Graying of AIDS, a person with multiple chronic conditions – or “MCCs”– might, for example, be living with HIV/AIDS as well as one or more of the following conditions: addiction disorders, arthritis, dementia, diabetes, heart disease, kidney disease, and mental health concerns like depression.)

Among the compelling statistics from the DHHS report cited in The New York Times:

  • 25% of Americans are living with two or more chronic conditions
  • Two-thirds of Americans over 65 and three-fourths of those over 80 have multiple chronic conditions (and the baby boomers are just starting to age into this demographic)
  • 69% of Medicare dollars are spent on people with five or more chronic conditions.

As the number of chronic conditions a person is dealing with increases, so do the risks of unnecessary testing and hospitalization, conflicting medical advice, negative reactions to medications, and poor health outcomes – including death. And from an economic perspective, “66% of total health care spending is directed toward care for the approximately 27% of Americans with multiple chronic conditions,” according to the report.

So what’s to be done?

The 16-page DHHS study, entitled “Multiple Chronic Conditions: A Strategic Framework” argues for changing the way our system engages these patients. It suggests that the problem is two-fold: first we need to do everything in our power to keep people healthy to begin with, including providing much needed support that will make it easier for patients to embrace critical disease-preventing lifestyle choices – including eating a healthy diet, exercising regularly, and quitting smoking – that have repeatedly been shown to improve health outcomes.

At the same time, we need a paradigm shift in how we think about disease management, one that moves away from a siloed approach that tends to deal with each condition in isolation and “[define] patients solely by their disease or condition” and instead embraces a coordinated care model and a “person-centered care approach.”

Communication and information sharing is central to this shifting approach. The increasing trend towards electronic health records will make the sharing of critical test results, medications prescribed, and other treatment information between providers much easier, but for the new system to truly be effective, patients need to do their part, too.  In an interview with The New York Times, Dr. Anand K. Parekh, an assistant secretary of health in charge of the report, noted that “when no one doctor coordinates and oversees a patient’s total care, or when patients neglect to report all the other prescribed and over-the-counter remedies they take, medical cocktails can become Molotov cocktails.“  The recommended shift to a patient-centered model – and the need for better communication and increased cultural competency that it necessitates — does not come naturally to everyone, and the report goes on to call for relevant information and training, along with “best practice” guidelines and other valuable tools, to be integrated into care provider training programs and work environments to facilitate this change.

Treatment success can mean different things to different people, and again communication is critical if providers are going to determine what is best for a patient. A geriatrician interviewed for The New York Times article noted that “patients with multiple conditions should always be asked what their goals are: to live as long as possible, to be as functional as possible or to be as free of symptoms as possible?” The doctor, geriatrician Mary E. Tinetti, suggests that every treatment for a person with multiple chronic conditions may have unintended effects on other systems in the body, so “whenever new treatment options are explored the patient or caregiver should ask, ‘What’s this going to do to my other health problems?’” Having a primary “overseer” of a patient’s care — often a primary care provider — can help to insure that the overall care a patient receives is in keeping with their own vision of treatment success.

Finally, the report calls for research into the lived experiences of people with multiple chronic conditions, the epidemiology of MCCs and “the constellations of conditions that are most prevalent,” and the strengths and weaknesses of different care models.

The challenges associated with multiple chronic conditions will only increase in the coming years as the baby boomer generation continues to age. As Brody notes in her New York Times article, “by 2020, the number of people with multiple chronic conditions is expected to increase to 81 million, up from 57 million in 2000.” So… What are we going to do about it? Let’s talk.