Need for systematic approach to care of high-need, high-cost patients

It is estimated in the US that 50% of healthcare expenditure is accounted for by 5% of patients. These are described as ‘high-need, high-cost’ (HNHC) patients, people with multiple chronic conditions that are often complicated by a limited ability to care for themselves independently and by complex social needs. Many are elderly but these HNHC patients often require many years of care with chronic disability and dependency.

A recent review in the New England Journal of Medicine pointed out that some of these HNHC patients have multiple chronic conditions that are stable with treatment and will persist for years, while others have extreme functional limitations. Some have severe, persistent behavioural health challenges. Other HNHC patients have conditions that are greatly exacerbated by social factors such as lack of housing, food and supportive personal relationships.¹

While we can readily recognise these patients – they account for the majority of people experiencing extended waiting times on trolleys in our emergency departments – we have been unsuccessful in developing efficient and effective ways of defining and addressing their needs. This is partly due to our tendency to narrow our practice to special interests and fail to resource a more holistic generalist community-based approach to healthcare. There is also a lack of systematic thinking and programmes to deal with HNHC patients that can be evaluated in terms of outcomes and resource utilisation.

The NEJM article by Blumenthal et al describes some programme models that have demonstrated success in meeting the needs of HNHC patients.¹ Some models focus on managing transition of care – for example, from hospital to home/rehabilitation facility/nursing home – that are common but risky for patients with complex conditions. Some models extend primary care teams by integrating non-medical services. Other models focus on interdisciplinary, person-centred primary care including: the Geriatric Resources for Assessment and Care of Elders (GRACE) programme and the Program of All-Inclusive Care for the Elderly (PACE), which was developed in San Francisco several decades ago and has spread to 118 locations in 32 states.¹

Successful interdisciplinary primary care programmes share a number of attributes, according to Blumenthal et al, including:

Careful targeting of interventions to people most likely to benefit (thus the need for segmentation of the population)

Close (usually face-to-face) communication and coordination among members of the care team, including physicians, nurses and care managers

Strong information technology support and promotion of patient and care-giver engagement in the care process.¹

Not only do high-need, high-cost patients absorb an increasing proportion of the healthcare budget, they also divert resources from patients with simpler, but serious, problems. Ignoring this problem is already causing health systems to seize up.

Reference

1. Blumenthal D et al. Caring for High-Need, High-Cost Patients — An Urgent Priority. N Engl J Med 2016; 375: 909-911