Addressing the needs of high users of the health system: where do you start?
Across Canada, health system leaders are recognizing the need to provide more effective and more efficient care to the highest users of the health care system. In December 2012, the Ontario government launched an ambitious Health Links strategy to better address the needs of the top 5% of health system users, who consume two thirds of the total provincial health budget. In October 2013, the Saskatchewan government announced the launch of pilot initiatives in Saskatoon and Regina to target the top 1% of patients who consume an estimated 1/3 of all health care resources in each region. Similar initiatives are underway in British Columbia and Alberta.
While these government-sponsored strategies are new, high user initiatives are not and there is something to be learned from those launched at the local level in Canadian communities over the past decade. One of these is the Défi Santé initiative in Quebec which was supported by the Canadian Foundation for Healthcare Improvement. The project focused on applying emerging best practices from international literature to make tangible improvements in care for the high users of the Sainte-Agathehealth care network in Quebec. At project initiation, the network was experiencing significant financial problems and capacity issues. The 115 acute bed network was operating at 115% capacity with a shortage in nursing staff and a reliance on over-time staffing.
The key question being tested in the project was: “Instead of simply cutting services or changing the staffing mix of the health network, is there a way to sustainably reduce both the patient volume in the emergency room (ER) and bed utilization?” Accomplishing this task required the network to focus on those who disproportionately used the ER and were admitted for treatment – the top 5% of patients.
The Défi Santé approach involved a detailed action plan, but at its heart it focused on realigning internal nursing capacity to have two dedicated case managers focus on improving care for the frequent user cohort. This approach was based on the UK’s NHS community matron model and focused on transitioning patients from chronically ill to chronically well5. Integral to this approach was results tracking and performance monitoring in order to adjust care management strategies and case manager case loads. The initiative also began to introduce the Wagner chronic care model across the organization more broadly.
The initiative has been enormously successful, with reductions in the use of the emergency department and acute care beds, as well as improvements in the patient health status. Today, the project has been implemented, or is in the process of being implemented in more than 40 health care organizations in Quebec.
Through Défi Santé, there are learnings that may be useful for other provinces as they redesign care to better meet the needs of high users of the health care system.
Lesson #1: Stratify your high user population into frequent user and long-user sub-populations
The high user population is actually made up of individuals with differing health problems, demographic characteristics and utilization profiles. It is essential at the outset of a high-user initiative to recognize that the high user population is actually composed of two distinct groups of patients: frequent users (frequent visits to the ED and repeated hospital admissions and long users (prolonged stays in hospital, including patients waiting for an alternate level of care). While both of these sub-populations have poor health status and consume a significant amount of health system resources, they have fundamentally different challenges and require very different clinical and administrative interventions.
The Défi Santé experience shows that it is much easier to improve care and reduce utilization for the frequent user cohort as compared to the more intractable long user population. There is a much greater return on investment in initially focusing organizational capacity on improving care for these frequent users.
Lesson #2: Think Big (or “big enough”)
The Défi Santé experience suggests that organizations can receive a significant return on investment from tackling frequent users only if a sufficiently large patient cohort is included in the initiative. For example, reducing the utilization of 25 frequent users may improve the health status of those individuals, but it is insufficient to allow local healthcare providers to fundamentally realign capacity. Modeling is required at the out-set of a frequent user initiative to determine the appropriate cohort size and the performance improvement required to deliver a clear return on investment.
Lesson # 3. Clinical buy-in requires targeted engagement based on timely, meaningful patient-level data
Frequent user initiatives cannot succeed without the active participation and leadership of clinicians. The same data that compels administrative leaders to act, however, is insufficient to mobilize physicians and other clinicians. The Défi Santé experience found that physicians became engaged when they were provided with patient-level data so that they can review the clinical history of individual patients. It is critical that this information is accurate, timely and actionable. If the data is a year old and many of the identified patients have died, it is clinically meaningless and can actually undermine credibility. For this reason, while an initial portrait of frequent users can be pulled from administrative databases, IT solutions that provide up-to-date, patient-level data on frequent users can greatly improve physician engagement.
Lesson # 4: Sustaining progress requires ongoing monitoring and management
Managing frequent users is like air traffic control – once you have dealt with the current priority patient another immediately appears on the horizon. The Défi Santé initiative addressed this by dedicating nurse case managers with improving the care coordination for a roster of patients. Patient level data was monitored continuously with new frequent users added to the roster replacing patients who have been successfully stabilized. This was made possible by an IT solution, Med-GPS, that allowed access to patient data in real time. This solution allowed monitoring of what was happening with the current frequent users and at the same time flag the potential next frequent users to reduce the likelihood that they would become future frequent users.
As provinces across the country launch new initiatives to address the needs of high users, we hope some of these experiences and lessons learned may be helpful to others on the same path.
Jean Mireault is the Chairman and Vice-President of Clinical Affairs for MediaMed Technologies. France Laframboise is a consultant in clinical performance and integrated management of chronic conditions. Tom Closson is president of Tom Closson Consulting.