Tuesday, October 24, 2017

Health care homes won't solve chronic disease



The establishment of medical homes based on voluntary general practice registration has begun formally, and quietly.  
At the start of this month, the first 22 Health Care Homes pilot sites began registering their patients with chronic illness, with another 180 due to go live in two months’ time.
The Federal Government has agreed to pay practices lump sums of $591 a year for patients with mainly self-managed illness, $1267 for those with moderate illness and $1795 for patients with chronic and complex needs, including palliative care.  In return, these homes will provide continuing primary care for these patients  delivered by a team of health care professionals. 
The Health Care Homes reform will finally test the effectiveness of the medical homes model that has been lauded for many years as key to improving the care of those with chronic and complex problems.
We must be clear from the start that Health Care Homes is not going to be the only solution to chronic disease care — but it could be one of the solutions. 
Over the next five years, if medical homes become part of the Australian healthcare system, it will be important not to overload them with too many expectations.
Instead, we’ll need to assess what they do — and don’t — do well.
The reality is that although serious and continuing illness take up to one-third of GPs’ time and fill the majority of hospital beds, we have been slow to adapt our way of managing them.
These illnesses are usually defined in the life of the patient by intermittent acute episodes. It is these events that can and should be better managed in their early stages, by community-based practitioners who know the patient and can determine what is best — rather than an ambulance automatically being called.
Yet, the infrastructure — practice management, staff and support — to effectively provide this kind of care is expensive. Whether the proposed Health Care Homes fee structure will be adequate remains to be seen. 
From experience, however, I can say that such trials often fail to demonstrate the effectiveness of major changes in care delivery. 
Over the past few years, I have been involved in three experimental programs in western Sydney designed to better integrate care between hospital and general practice for patients with chronic illness.  
The first two are now complete, revealing there is serious unmet healthcare need in the community, and that the pursuit of integrated care as a way to reduce costs, at least in the Australian setting, may be in vain.
Such trials may make for greater practitioner and patient satisfaction, but we found no measurable decrease in hospital admissions.
What we did find was a need for increased investment in supportive community-based services.
Part of the explanation for this is that our understanding of the life of a patient with serious and complex illness is often incomplete.
Another study we undertook used in-depth patient interviews to determine their perceptions of what they needed.3 I learned two powerful lessons.
First, I came to realise how dependent such patients are on family and friends. Only a tiny proportion of their care — let’s say 10% — came through the healthcare system.  
We need to be careful not to kid ourselves that rearranging what we doctors do will make a huge difference to them.
Second, serious and continuing complex illness is a slippery slope to poverty. Carers, not just patients, quit work. Travel is time-consuming and expensive, and many ancillary aids are not covered by the PBS or other government funds.  
I am not saying for a moment that the medical home model is a flawed idea that should not be tried. It should be.
But in our approach, we should keep in mind that patients with chronic diseases are often in deep and complex trouble. Their needs are multiple and extend from money to loneliness.
And, while our healthcare system is generous by world standards, it cannot alone meet more than a fraction of their needs.  
Anyone expecting Health Care Homes to reduce the cost of healthcare is looking in the wrong place. Providing high-quality integrated care (including the many social needs of these patients) is going to cost money, and lots of it.  
However, if we consider the care of these people to be part of the mission of medicine, then we need to press on and advocate for adequate resources to do the job well.
This article first appeared on the Medical Observer website. http://bit.ly/2y3unzC

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