Learning While Caring: Advancing Patient-Centered Care for People with Multiple Chronic Conditions

MAY

2019

Arlene S. Bierman, M.D., M.S., and

Gopal Khanna, M.B.A.

The primary aim of the health system is to care for people, their families, and communities using the best available evidence to attain the best achievable health outcomes. AHRQ has been at the forefront of these efforts over our now 20-year history.

Yet, every day many people and their caregivers struggle to find care that effectively addresses their needs. Clinicians, too, are frustrated, experiencing epidemic levels of burnout while working in systems often ill-designed to support them in addressing these fundamental objectives of healthcare delivery. This challenge is particularly pronounced for the nearly one of three American adults, and four of five Medicare beneficiaries, who are living with multiple chronic conditions (MCC).

Patients with MCC account for 64 percent of all clinician visits, 70 percent of all in-patient hospital stays, 83 percent of all prescriptions, and 71 percent of all healthcare spending. Alarmingly, the Agency’s Multiple Chronic Conditions Chartbook (PDF, 10.88 MB) shows that the number of children and adolescents with MCCs is growing, as well.

In our most recent AHRQ Views blog post, we described the Agency’s overarching vision to improve patients’ lives. In this time of enormous change in healthcare, AHRQ is poised to seize the growing opportunities to tackle healthcare’s most pressing challenges. As the Federal agency tasked with advancing the science of healthcare delivery—rather than with curing a particular disease—AHRQ is uniquely positioned to identify ways for developing a sustainable healthcare system that delivers high-value, coordinated, and integrated patient-centered care based in primary care to optimize individual and population health by preventing and effectively managing multiple chronic conditions.

Healthcare systems are increasingly challenged to effectively address the needs of people with MCC. Currently, there is a critical mismatch between the way care is delivered (disease-specific) and the needs of people with MCC, who require whole-person (patient-centered) care. This disconnect too often results in care that is fragmented and of suboptimal quality, leading to poor outcomes and increased costs.

Furthermore, practice guidelines that help clinicians make testing and treatment decisions tend to guide the care of each one of the patients’ conditions in isolation. One consequence of this narrow scope is that recommended treatments for one condition may interact harmfully with recommended treatments for another one.

Navigating the fragmented health system imposes burdens on patients while stressing their caregivers, families, and healthcare providers alike. Despite the overwhelming prevalence of MCC, the high burdens they impose, and the vast resources they consume, little attention has been focused on improving care for those with MCC, or on preventing MCC in at-risk individuals and communities.

To achieve our vision for a high-performing healthcare system, more evidence is needed on effective strategies and capacity to provide integrated primary care within “medical neighborhoods,” with a 360 degree view of the needs of people with MCC. The care patients receive must address individuals’ goals and preferences in the context of their lives. New primary care models need strong linkages with public health, community services, and other sectors that address the social determinants of health. By taking a transdisciplinary approach, AHRQ research can determine what works for which individuals and communities and how to make it work.

We need to do much better. This lack of attention demands an urgent response.

As a first step towards realizing this vision, AHRQ needs to put forth a well-conceived and effectively executed research agenda. The Care-and-Learn Model, developed by AHRQ researchers to map the work of the Agency and its research portfolio, will help identify areas of unmet need and prioritize research questions with the most value for advancing the care of people with MCC. The Care and Learn Model starts by placing the patient at the center of care. It encourages learning about how best to care for patients by closely evaluating how well patients are doing and identifying which of their needs are not being met.

The model aligns the two primary functions of the health system: providing care that meets the needs of diverse individuals and populations and continually learning by implementing evidence and using data to increase our understanding of what works. The Care-and-Learn Model brings together essential caring functions with data-driven evidence generation, synthesis, and implementation.

To improve care for people with chronic conditions, health systems research is needed to develop:

Evidence and guidelines that take into account the cumulative and interactive effects of multiple conditions along with the burdens of treatment.
New ways of coordinating care that overcome traditional silos and support teamwork.
Innovative uses of technology to bring evidence to the point of care and enable effective care coordination and integration.

AHRQ has already launched important initiatives to improve the care of people with MCCs. The Academy for Integrating Behavioral Health and Primary Care is a national resource that provides information and tools for more effectively integrating patient care. New research funding has been made available to help primary care teams diagnose and manage unhealthy alcohol use. Another funding initiative is exploring data analytics to improve chronic disease management.

Meanwhile, an AHRQ-sponsored competition has challenged innovators to develop an app to make greater use of patient-reported outcomes. By supporting research to develop, implement, and evaluate effective models of care for MCC and to develop innovative digital health solutions to improve care we provide the evidence that is long overdue to foster transformation of the health system to optimize outcomes for those with the greatest need.

By producing, implementing, and nationally scaling the evidence to transform care for people with MCC, we can improve individual and population health simultaneously, reducing the burdens on patients, caregivers, and clinicians while increasing the value received from health care spending.

Arlene Bierman is Director of AHRQ’s Center for Evidence and Practice Improvement. Gopal Khanna is Director of AHRQ.

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