Does the Management of Complex Patients have to be Complex?

With thought and planning, complex patients can be managed well in a primary care environment. In fact, no one is better prepared to manage these patients than you--the primary care provider.

Managing complex patients successfully involves implementing best practices, using data to identify opportunities for improvement, measuring outcomes, and creating a cycle of continuous improvement. 

This two-part series focuses on key areas that facilitate the management of complex patients. First up is understanding the role of the primary care physician and understanding who your patients are. Part two will focus on providing proactive care and measuring results.

Understand Your Role

Although a team-based approach is critical to managing complex patients, physicians should always have a lead role, as they have the training, education, and experience to help direct all members of the care team. Successfully managing complex care requires physician involvement in many different areas.

• Definition and diagnosis. No one in the health care system is better equipped than the primary care physician to define and familiarize a new or worsening diagnosis to a patient. This includes the condition''s short and long-term consequences, recognition of early exacerbations, and most importantly, how to engage patients in managing their own illnesses.

• Coding/complications. The accurate coding of a patient's diagnosis and their complications feel like an administrative burden to physicians, but leaving it to others can lead to errors.  ICD-10 codes are used to stratify a patient''s risk and identify those who need clinical interventions and outreach. Without accurate coding, it is impossible to identify your most complex patients.  For example, if you don''t code a diabetic as having Ophthalmic complications, your care team won''t be focused on those patients in most need of Ophthalmology follow-up.

• Care coordination: Great care doesn't happen with primary care alone. You are in the best position to know who in your community of specialists communicates well, shares important information in a timely fashion, and gets the best clinical results. Defining a network of like-minded specialists will improve your ability to deliver the best outcomes for patients.

Know Your Patients

To manage your complex patient, you must be able to answer three basic questions:

• Who are my complex patients?
• What illnesses and complications do they have?
• Where have they been in the healthcare system?

In insurance speak - attribution, acuity, and utilization.

Attribution: Payers attribute patients to physicians based on the frequency and intensity of their primary care visits. In the simplest terms, if you see a patient more than any other primary care physician, the patient is likely to be attributed to you.

Attribution is important because payers measure the cost and quality of your services against national and local results based on your attributed patients. Complex patients disproportionately impact your cost and quality results.

It's common to have complex patients who you frequently see attributed to you. But what about a complex patient who sees multiple specialists but sees you infrequently, and only for simple acute problems? Such patients, and all their associated quality gaps and specialty costs, are also being attributed to you.

Without having any opportunity to help manage their care, you are left to rely on specialists to provide a coordinated clinical experience and document quality and risk codes.  Just as important is the healthy patient who has limited contact with the healthcare system. This patient may find himself unattributed, even though he or she believes you are their physician. 
It sounds simple but the key to attribution is seeing your patients, both the sick and the healthy.

At my practice, Village Family Practice (VFP) in Houston, Texas we use the annual wellness visit (AWV), a high-intensity visit that focuses on precise coding to capture an accurate acuity level, screening tests to close gaps in care, and preventative services, as the visit that helps drive attribution. The AWVs on our most complex patients are conducted by physicians; those patients with less complex problems are scheduled with our nurse practitioners, physician assistants, and clinical pharmacists. 

Acuity: Physicians have an average practice panel of 1,500 patients, with 20 percent (or 300) of those patients typically consuming the majority of health care resources in your practice. Can you name your 300 patients?

Knowing the acuity level of patients helps providers prioritize patients, making sure the most complex patients are seen more frequently and have access to the resources they need. Acuity levels are determined by risk acuity scores. The score is determined by a patient''s ICD-10 diagnosis, the more complex the diagnosis the higher the score and the higher the acuity.

Utilization: To successfully manage a complex patient population, you have to know how patients are utilizing the healthcare system--when, where, and why patients have been seen, across the system, including primary care, specialty care, emergency department (ED) visits, and most importantly hospital admissions.

Claims data can provide a historical look back, but are often too old to be useful. Most of us get notifications of ED admits, hospital admissions, and specialty consults from our physician colleagues. Finding a way to make a note in your electronic medical record (EMR) of very simple utilization data such as ED visits can greatly improve identifying patients who need more attention.

Utilization and quality are most accurately measured by combining EMR and claims data. Doing so allows you to view utilization both inside and outside of your practice. Once only available to large groups, this data is now available through independent physician associations, management services organizations, health information exchanges, and practice management companies. 

Dr. Clive Fields is president of the Village Family Practice and co-founder/chief medical officer at VillageMD.