Team-Based Health Care Model Reduces Need, Improves Quality of Life for Complex Patients, Study Shows

By Scott Maier

A complex care model that is interdisciplinary and team-based and utilizes home visits reduces health care need and improves quality of life for medically complex patients, according to researchers at UC San Francisco and the affiliated San Francisco VA Health Care System.

The study appeared online Feb. 12, in PLOS ONE.

“There is growing evidence that complex care models that involve home-based assessments effectively reduce high cost health care utilization, such as readmissions and emergency use, while simultaneously improving patient quality of life, and will be extremely important ‘anchor programs’ for health care delivery systems in the current era of payment reform,” said study author Gina Intinarelli, RN, PhD, MS, executive director of UCSF Office of Population Health and Accountable Care (OPHAC).

“This study provides confirmation of the benefits of these home-based assessments. As baby boomers age and our elderly population experiences unprecedented growth, we will see a significant expansion of these types of programs as health delivery systems realize the importance to their fiscal health.”

Care Support Reduces ER Visits and Hospitalizations

Patients requiring complex care have needs complicated by significant medical and psychosocial factors, such as multiple chronic conditions and comorbid physical and mental health conditions.

In the study, the team adapted a program at Indiana University known as the Geriatric Resources for the Assessment and Care of Elders (GRACE) program, which has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers. Developed to improve care while controlling costs for older patients with complex care needs, GRACE incorporates a nurse practitioner/social worker (NP/SW) team that performs comprehensive, structured assessments in patients’ homes and then meets as part of a larger interdisciplinary team that includes a geriatrician, mental health liaison and pharmacist.

The researchers evaluated an adaption of the GRACE model to meet the needs of very complex, non-elderly patients in a program called Care Support. They evaluated 154 high-risk patients from four primary care medical clinics at UCSF Medical Center who had more than five emergency room visits or two hospitalizations between April 2013 and May 2014.

Patients received a comprehensive in-home assessment from an NP/SW team. These teams then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant health issues as needed.

Through Care Support, the researchers saw a significant decline in emergency room visits and hospitalizations six months before enrollment compared to six months after. Patients reporting better self-rated health increased from 31 percent at enrollment to 64 percent nine months later. Those who benefitted the most had multiple, complex conditions, little community support and mild anxiety.

As a result, the GRACE/Care Support program proved feasible for adults. Patients experienced significant reductions in acute care utilization and substantial improvements in self-rated health.

“Patients with complex care needs benefit from a comprehensive assessment in their home environment and a team-based approach to care,” said lead author Christine Ritchie, MD, MSPH, professor of geriatrics at UCSF and director of clinical programs in OPHAC. “This strategy can have a major impact on health care costs and improve patient outcomes.”

The researchers noted further study is needed that goes beyond the self-reporting by patients to affirm potential application outside an academic medical center; that does not include a mental health professional on the team, as this individual may not always be available; and that does include a cost-benefit analysis to determine potential savings.

“Based on the success of Care Support, the program is being integrated into the larger UCSF health care system,” said senior author Deborah Barnes, PhD, MPH, associate professor of psychiatry and epidemiology and biostatistics at UCSF and researcher at the SFVAHCS. “The success of this model and the improvement in health of our sickest and most vulnerable patients has allowed us to expand our team and reach out to many more patients.”

Other UCSF Health contributors to the PLOS ONE study were Robin Andersen, NP, family and community medicine; Jessica Eng, MD, MS, assistant professor of geriatrics; Sarah Garrigues, project manager of Tideswell at UCSF; Helen Kao, MD, geriatrician at the Center for Geriatric Care; Suzanne Kawahara, MBA, deputy director of Tideswell at UCSF; Karen Patel, MBBS, MPH, Tideswell at UCSF; Lisa Sapiro, licensed social worker in geriatrics; Anne Thibault, RN, MS, NP, complex care coordinator in general internal medicine; and Erika Tunick, MSW, clinical social worker at the Center for Geriatric Care. Funding for the evaluation was provided by the S.D. Bechtel, Jr. Foundation.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and UCSF Health, which includes two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco, as well as other partner and affiliated hospitals and healthcare providers throughout the Bay Area.