The Comprehensive Care Clinic

Abstract

Management of chronic diseases has been a recent focus of health care because of its effect on quality of life, health care use, and cost (Holman & Lorig, 2000). However, most of the interventions geared toward chronic disease management have been disease specific and do not address the issue of comorbidity, defined as an additional disease beyond the condition under study that increases a patient's total burden of (Klabunde, Warren, & Legler, 2002, p. 26). Previous studies of older adults have demonstrated the importance of comorbidity in affecting the number and type of health care services sought (Westert, Satariano, Schellevis, & van den Bos, 2001), functional abilities (Dunlopp, Manheim, Sohn, Liu, & Chang, 2002), and general health (Wensing, Vingerhoests, & Grol, 2001). In a review of current management strategies for chronic diseases, Davis, Wagner, and Groves (2002) stated that people with chronic comorbid diseases have common concerns and face similar challenges, such as coping with anger and dealing with role function changes, that are not often addressed in disease-specific self-management programs (Lorig et al., 1996). Disease-management vendors, such as case managers, who provide services specific to a disease or syndrome, are now finding it necessary to merge with other companies to provide comprehensive all-disease management to patients with multiple chronic comorbid conditions (Carroll, 2002). The problem of comorbidity is well represented in the elderly veteran population. Given its rapid growth, an important goal for the Department of Veterans Affairs (VA) is to develop effective interventions to help elderly veterans better cope with their chronic comorbid conditions. This article describes a clinical demonstration project, the Comprehensive Care Clinic (CCC) in the West Los Angeles VA Medical Center, implemented by its Geriatric Research, Education, and Clinical Center (GRECC) outpatient clinic staff that aimed to serve this need. The CCC was an interdisciplinary team effort to serve the psychosocial and medical needs of a population of elderly veterans with chronic comorbid conditions and who were perceived as high users of health services by their GRECC providers. The CCC consisted of a monthly group clinic supplemental to the patients' outpatient primary care clinic appointments and provided increased access to their health care team, closer monitoring of chronic illness symptoms, and education for self-care and encouraged social support among its members. It began in January 2001 and ended in December 2001. METHOD Sample The sampling method for the CCC was based on the Kaiser Permanente Cooperative Health Care Clinic model (Kaiser Permanente, 1993). The GRECC clinic interdisciplinary staff, composed of physicians, a nurse practitioner, a social worker, a pharmacist, a psychologist, a nutritionist, and a program assistant, was given rosters of the clinic patients and asked to recommend patients for the CCC based on eligibility criteria developed from the Kaiser Permanente model: * Frequent flyers or those who sought unscheduled care at least 10 times per year (phone calls, emergency room visits, urgent care, unscheduled primary care visits) as determined by GRECC interdisciplinary staff * Minimum of two chronic disorders * No terminal illness * No cognitive impairment as measured by a Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) score of at least 24 * Able to transfer and toilet independently * No active substance abuse problem * Living in the community (no nursing home residents) * Primary care providers were GRECC staff Twenty-two patients were identified by the clinic staff as potential participants from a roster of 200. Procedures and Interventions Telephone Needs Assessment. The identified patients were contacted by telephone, introduced to the concept of the CCC, and asked about their health care needs, patterns of VA services use, and interest in attending a group clinic, using a needs assessment instrument developed for this pilot program (see Table 1). …