When patients have a number of comorbidities and have several exacerbations per year, we know a great deal about their healthcare use. However, we are typically not utilizing this information to its fullest potential. For people who are very ill, with several comorbidities, expensive emergencies do not happen out of the blue and an analysis will demonstrate that there are usage patterns. If we can better understand these patterns, we can intervene before, rather than after things get worse.
Anticipatory or proactive care approach means working with patients and their caregivers to establish how they can deliver some aspects of care in their home. Patients are likely to respond well to an intervention that limits the medical emergencies that makes their lives feel fragile. This is not only about preventing the exacerbations of a chronic condition, it is also about giving power back to the patient and helping them regain the sense of control that is often lost when trying to manage multiple conditions.
For coordinated care around the person to become a reality, people with multiple co-morbidities will need direct support. At the core of this will be a clear, coherent care plan that is worked out with the patient and their caregiver, placing a single, nominated care coordinator alongside the patient, above the individual specialists.
Patients and caregivers already do a lot of care delivery themselves. It is important that any model of coordinated care formalizes this and makes this more effective by establishing goal-based care, shared decision making, a focus on wellness and health literacy. This is not just the right thing to do, is likely to improve outcomes and reduce the use of resources. Another report in the What Works series, Creating new value with patients, carers and communities, explores these issues in more detail.6
In 2014, KPMG International commissioned research that engaged with patient groups in six countries, across a number of different diseases.
One of the key messages from this study was that there are critical points along a typical care pathway where patients feel ‘abandoned’, and health outcomes may suffer as a result. One example is the point immediately after diagnosis of a long term condition – before the patient is likely to have had fairly intensive contact with health professionals, but after which there is often a sudden drop off in support and advice.
This is a particular issue for elderly patients, those with dementia and other mental health problems, and patients with complex co-morbidities.
One system that is trying to bridge these support cliffs is the province of Nova Scotia in Canada, where the day after someone is diagnosed with cancer, a trained patient navigator is in touch. The navigators are oncological nurses working in the community to provide a single point of contact to help guide, educate and advocate people through the experience of cancer. The navigators help people to understand their condition, establish their priorities, make decisions and cope with the workload often involved in being a cancer patient or caregiver.
6. KPMG International,2014.