Multifaceted Interventions Needed for Complex Medical Landscape

Abstract

GRAPEVINE, TEXAS — In her presentation at Saturday’s General Session at AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference, Joan Teno, MD, MS, said she wanted to “shine a light on the things we need to think about as we look ahead” at the future of health care. Dr. Teno, a renowned health services researcher in Seattle, WA, observed that, historically, primary care physicians saw the patient across settings of care. “Marcus Welby [the 1970s television physician] did it all. That was the model I grew up with, but it isn’t the practice of medicine we have today,” she said. “People now encounter multiple types of ‘ist’ physicians [such as SNFists or hospitalists] who are increasingly specialized in one care setting. We need people who specialize, but it’s difficult for patients to have so many providers involved in their care.” This is especially challenging for patients with dementia, as they increasingly see many practitioners beyond their own familiar “Marcus Welby.” “For individuals with advanced dementia, we can document changes in the type of physicians caring for these persons and the continuity of care from the nursing home to the acute-care hospital,” Dr. Teno said. Using Medicare claims data between 2000 and 2010, Dr. Teno and her colleagues found that over time the care provided by primary care physicians has decreased dramatically. They also determined that people who end up in the hospital tend to have multiple physicians. “The number of physicians the patients and families have to deal with has gone up dramatically,” she said. Whereas patients see more physicians in the acute care setting, Dr. Teno noted, they seem to be seeing fewer in the nursing home. “The number of physicians billing in the nursing home setting has decreased from 13.7% to 9.8%,” she said. Increasingly, nurse practitioners and physician assistants are providing more of the care in this setting. However, there is a growing number of physicians who practice exclusively in nursing homes, and the number of physicians billing exclusively in this setting has increased significantly. Dr. Teno said she was concerned about the impact of these changes to the traditional patient-physician dynamics on patients with dementia. Increasingly, “we’re seeing a lack of continuity of care for these patients,” she said. This potentially can lead to medical errors, a lack of coordinated treatment plans, burdensome transitions, hospital readmissions, and poor perceptions of quality. “We see unmet needs for spiritual support, and patients and families sometimes feel like they’ve been disrespected and not involved. Care goals often don’t match patients’ wishes,” Dr. Teno said. “Those with late transitions were less likely to rate care as excellent, more likely to be treated without respect . . . and experienced worsened communication.” This presents an opportunity for significant quality improvement. “We currently are treating elders with serious illnesses as ‘hot potatoes.’ We push them around and try to put the responsibility on someone else,” Dr. Teno said. Changes need to be made, she noted, adding that “it is important that we be involved in the debate and think about the unintended consequences of what we do and how the system works. We need to create a payment system that allows patients to spend time in the least restrictive setting. We need to develop innovative programs that are not built around payment but around the needs of patients and family.” Single-focused interventions will fail, Dr. Teno cautioned. “We need multifaceted interventions . . . that embrace complexity,” she said. Toward this end, education is important, but education alone is not sufficient if the economic incentives are not aligned with high-quality care, she said. Going forward “we need to change the culture and move away from the over-reliance on prognostic models,” Dr. Teno said. “Anything we do needs to be thoughtful about inaccuracies in prognostication and risk.” Senior contributing writer Joanne Kaldy is a freelance writer and a communications consultant for the Society.