Working with complexity: Applying the right intervention to address avoidable utilization in primary care

Introduction: Providing primary care for complex patients requires alternative modalities and goals. While “complexity” can be defined in different ways, it generally refers to when evidence-based medical recommendations... [ view full abstract ]

Introduction: Providing primary care for complex patients requires alternative modalities and goals. While “complexity” can be defined in different ways, it generally refers to when evidence-based medical recommendations are unlikely to be successful due to biopsychosocial and systemic reasons, which can result in frustrated relationships, reduced quality, and higher costs. Innovative care delivery approaches are required to meet the needs of complex patients in patient-centered and cost-effective ways.  

Methods: This project took place at a family medicine-based community health center and focused on patients with high utilization of the Emergency Department and/or high rates of rehospitalization within 30 days of discharge. Interventions included a) embedding an Urgent Plan of Care into the triage system to identify concerns beyond symptoms, b) creating a team-based model of hospital follow-up to help discharged patients transition to home, c) implementing a “Complex Continuity Clinic” for patients for whom traditional care is not working, which included an extended visit with multidisciplinary team members.

Results: This multi-method project used quantitative measures to look at rates of ED utilization, hospital readmission, no-shows, care plan completions, and cost; and qualitative measures to explore the provider, team and patient experience, including provider, staff and patient satisfaction and engagement. Results showed reductions in ED utilization, a better understanding of discharged patients’ needs, and increased patient activation and team cohesiveness.

Discussion: Going beyond problem-focused methodologies to address issues embedded in a complex adaptive system enables a relationship that supports highly variable biomedical, social, psychological and cognitive needs of patients.