Solving complex cases with compassion

UNC's hospitalists work across disciplines to find solutions for complex patients.

Solving complex cases with compassion click to enlarge Kelly Stepanek, NP, Beth Brubaker, MD, and Andy Donohoe, MD

By Kim Morris, Department of Medicine

The scenarios played out the same with dangerous patterns for everyone. RX database records showed a woman with a chronic disease had traveled I-85, from eastern Virginia to Greensboro, receiving over 13,000 mg of Oxycodone and 12,000 mg of MS Contin in one year’s time. A homeless man frequented the ER with a pain crisis at least five times a month. Another man, trying to finish his degree, had 102 hospital days in one year, staying a week or more at a time.

Hospitalist Beth Ann Brubaker, MD, knew the social determinants of health were just as important as the medical pieces when it came to caring for patients with both a chronic disease and a complication related to mental health, an addiction, or another condition. With Andy Donohoe, MD, and Kelly Stepanek, NP, from the division of hospital medicine, Brubaker pored over patient records and she saw the patterns--well before the opioid epidemic was declared a national health crisis.

These complex patients were coping with different issues, including chronic pain, mental health or end-stage disease. They were also living with difficult social and financial situations. The solution required a multidisciplinary approach, connecting hospital medicine and ED physicians with specialists in psychiatry, pain psychology and ethics, combined with outpatient clinics—like sickle cell and diabetes providers—and case/utilization managers.

“We needed to change how we were serving these patients, to meet their needs and reduce high hospital costs,” said Brubaker. “The challenge was to show compassion but not give in to what has been a pathological process.”

Brubaker and the committee took a rational approach to managing these patients known as super-utilizers, with high rates of ED use and hospitalization.  An individual care plan (ICP) would determine the most appropriate ED or inpatient care, that could successfully transition patients to the most appropriate outpatient and primary care. Patients could get the services they need, not just the health interventions. No matter who was on service, a plan would make consistent care.

“On any given day, these patients would come in demanding to be admitted, and if their labs looked even a little off, we were uncomfortable sending them home, especially when we didn’t know if they really would follow-up with a primary care provider.”

“This was very much about making consistency across our care and looking at the facts, moving away from what had become a flawed and futile standard. You can imagine how demoralizing it can be to go through the motions, doing something that you know isn’t working. Now--when we get hold of them, we don’t let go; we hold ourselves as medical providers, and the patient, to a higher standard.”

Working with the narcotic addicted patient, Brubaker intervened with the family. She gained the mother’s support, and she put a plan in motion that got the patient managing her own health with a primary care provider and outpatient clinical care.

“We settled only for the real answers, as much as we could possibly figure out. Then we rolled up our sleeves to do what needed to be done, often with unusual techniques.”

When Donohoe realized a patient was homeless, he reached out to the patient's church to help provide resources for housing. This kept the patient from needing to use the hospital for his chronic but stable medical issues, reducing his hospital utilization 100%.

“The fact that he didn’t have a place to live was exacerbating his condition and this kept him coming into the hospital,” said Brubaker.

The patient taking classes had chronic pain and a complicated condition that kept him coming in at least once a month. Part of his care plan was to get him into primary care and an outpatient clinic more intensely.

“As we pulled back, his primary provider came in closer. This reduced his hospital use by 82%. It wasn’t what the patient wanted initially, but he ended up being grateful and was able to finish his degree.”

The heart of the ICP model is the patient, but physicians are not inert in the process. They ensure care is consistent from the time of ED presentation and admission, until discharge, with coordinated outpatient services that keep the patient from having to return to the hospital.

The ICP also benefits physicians. Patients receive the care they really need and physicians can see these patients progress. Brubaker says it can impact a physician’s wellbeing, too.

“It's difficult to not become really fatigued taking care of the same person for the same thing over and over again, knowing the care is not addressing the "real" issues, and not really seeing any solutions over time.”

Individual care plans demonstrate the efficiency of practice and how a culture of continuous improvement can make physicians better equipped to practice the art and science of medicine.

Maintaining a balance between work and patient satisfaction is also critical to achieving the quadruple aim. Reducing physician and staff burnout can make the primary goal of the triple aim work, improving population health.


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