Patient Centered Medical Homes (PCMH) are built upon access, communication, continuity and ongoing performance improvement. Health Homes have been most successful in engaging marginalized difficult patients with little primary care utilization but falter when successful treatment requires care by multiple physician specialists, who most often cannot directly communicate; on the other hand, stable patients with chronic disease could frequently be cared for more efficiently in the community by non-physician providers. We at the Bronx-Lebanon Hospital Performing Provider System in the Bronx are building a new model: The Ambulatory Intensive Care Unit. The objective of the Ambulatory ICU is to develop a model of care that combines the virtues of the PCMH and the Health Home: Multi-provider team-based visits (Ambulatory ICU’s) for patients with complex medical, behavioral, and social morbidities.
Models of Care Integration
The integration of medical and mental health is promoted in several of the projects of the Delivery System Redesign Incentive Payment (DSRIP) projects. Most attention has been given to instituting Collaborative Care models for general medical patients with anxiety or depression. Primary care has been expanded through Patient Centered Medical Homes (PCMH) to include the provision of mental health screening and treatment. In the PCMH, primary care patients with depression receive enhanced follow-up and education through a Depression Care Coordinator (either an RN or social worker) within the medical practice. A psychiatrist consults regularly about problematic patients or those who are not improving as anticipated. The key point is that the primary care practice takes primary responsibility for initial treatment. The mental health system supplies support for these efforts through consultation and acceptance of referrals for patients with severe mental illness.
Improvements in the health care of patients with more severe mental illness have been more problematic. As is well known, patients with persistent mental illness have a markedly shortened life expectancy. Integration of general health care into mental health treatment sites is less developed than Collaborative Care for primary care. Patients with mental illness often have multiple debilitating medical illnesses requiring the care of multiple specialists. Not infrequently, there is little communication among these specialists. Health Home care coordinators make excellent alliance with patients, but they cannot be expected to repair a disorganized system.
High Utilizing Patients
Containment of health care costs has driven the development of the Ambulatory ICU. Because a relatively small number of patients account for a disproportionate share of health care utilization and cost, considerable attention is focused on improving the coordination of health care for such high need, high cost patients. The challenges posed by high utilizing patients with multiple co-morbidities are especially acute among poor inner city residents insured through Medicaid.
There have been several attempts to improve care for high utilizing patients. Programs in six counties in California were designed to address the needs of high cost Medi-Cal (Medicaid) patients and identified three key components of comprehensive care for high cost patients: (1) Instrumental outreach and engagement (e.g., use of incentives such as phone cards, grocery vouchers or transportation assistance); (2) multidisciplinary, ethnically diverse teams that met regularly for care planning and coordination with other agencies and hospitals; (3) partnerships among agencies, including hospitals, mental health and substance abuse providers, housing agencies, pain management specialists and legal services. Initial analysis suggested substantial cost savings.
Ambulatory ICU Sessions
The key points of the Ambulatory ICU team based care sessions are: 1) Patients registration by a familiar team member; 2) Review of visit agenda with team members in advance of the physician visit; 2) RN symptom review, vital signs, and delineation of need for specific tests for chronic disease management on this visit; 3) Generalist physician or Nurse Practitioner visit; 4) Psychotherapist visit when scheduled; 5) Psychiatrist or Psychiatric Nurse Practitioner visit; 5) Visit with social service expert, if needed; 6) Review of day’s findings and recommendation with the patient by one or more team members to be certain that the patient understands the plan; 7) Meeting with the community care coordinator to set up follow-up visits and schedule for community resource appointments (e.g., housing, exercise, NA/AA, Weight Watchers, or others); 8) Team review of care plan on a regular basis or whenever the patient has an Emergency Department visit or hospitalization. In addition to these activities, we plan to reserve specialist time (Endocrinologist, Gastroenterologist, Infectious Diseases specialist, Surgeon, others) for on-site or telemedicine consultation with the team and patient whenever indicated. We also will work intensively with inpatient teams should a patient be hospitalized and institute intensive transitional care that will involve a phone conversation within 24 hours of discharge, a home visit within 48 hours and a follow-up visit within 3 working days.
The Ambulatory ICU has roots in the theories of Disruptive Innovation as described by Clay Christensen and his colleagues at the Harvard Business School. In his terms, the Ambulatory ICU is a “Solution Shop” rather than the usual assembly line primary care, which Christensen calls a “Value Adding Process” (VAP). Solutions Shops address complex, unstructured and unique problems. Success depends largely on the training and expertise of the employees involved and access to sophisticated technology. An example of a solution shop business model includes the work of a consulting group when it brings expertise from multiple experts to bear on the problems of an enterprise. Those experts evaluate the unique problems of that one organization, hold extensive discussions among the consulting team, and offer an individualized set of recommendations. In healthcare, a solution shop might include the kind of detailed consultation offered at the Mayo Clinic, when a patient with a complex illness that has not been easily treated at other institutions is examined and discussed among a cross-disciplinary panel of experts, relevant tests performed, and a report discussed with a patient – all in one day.
A VAP business model uses predictable and routine processes to improve a product step-by-step and is most appropriate for routine, standardized procedures. Success depends primarily on the quality of the process. An example is a Toyota assembly line where each step is completed and perfected before moving onto the next task. Each stage of assembly is carefully documented and done the same way each time, rendering it suitable for Continuous Process Improvement. In healthcare, an example of a VAP problem would be the routine care of diabetes, wherein the hemoglobin A1c, eye examination, foot examination, dietary and exercise counseling, and use of appropriate hypoglycemic medications all need to be performed at prescribed intervals and in a reproducible manner.
Medical Assembly Lines
Think of the Emergency Department. The focus is on processing a particular patient as quickly as possible “up or out”. In either event, the ED physician then turns to the next “case”. Handoffs are rushed. If the patient is admitted, there is a brief discussion with the resident on call “on the floor”. That resident will leave the following evening or morning, signing out to the next resident who will discuss the patient with the inpatient attending physician. By that point, the patient’s primary care plan is a distant memory, if it were ever known. The patient’s primary care physician, even if notified, seldom has the time to be involved in the inpatient care. Care coordinators try to make sure that the patient keeps follow-up appointments. Medications are reconciled. A continuing care document is sent to the primary care physician. Perhaps a “Transitions Coach” nurse even makes a follow-up call. But who has really considered the meaning of this hospitalization in the patient’s life course? Who notices that this is the fourth admission for abdominal pain this year and that the CT scans obtained in the ED all show the same abnormalities? Who discovers that the abdominal pain recurs whenever the patient relapses on alcohol? Who understands that the patient relapses on alcohol whenever her son relapses on drugs and steals her medications and money? Can a Health Home Care Coordinator possibly know that the abdominal pain admissions were medically avoidable or that the radiological studies were excessive? Can a primary care doctor figure this out in twenty minutes? Can a psychiatrist possibly evaluate the patient’s abdominal pain? (This scenario is taken from a patient in our Health Home, whose history was elucidated only in our case conferences, which are similar to Solution Shops.) Or if a different patient visits different medical emergency departments with varying pain complaints and leaves each time against medical advice, who notes that her medical complaints and irritability relate to her worsened depression and opiate dependency? Who shares the insight and with whom?
The Ambulatory ICU will endeavor to go beyond coordination of current care and beyond the integration of primary and mental health care. It envisions a system in which the most complex patients get careful attention from the best experts, allowing care coordinators to do what they do so well: Engage patients on a rational journey toward better health.