With thought and planning, complex patients can be managed well in a primary care environment. In fact, no one is better prepared to manage these patients than you--the primary care provider.
Managing complex patients successfully involves implementing best practices, using data to identify opportunities for improvement, measuring outcomes, and creating a cycle of continuous improvement.
This two-part series focuses on key areas that facilitate the management of complex patients. First up is understanding the role of the primary care physician and understanding who your patients are. Part two will focus on providing proactive care and measuring results.
Understand Your Role
Although a team-based approach is critical to managing complex patients, physicians should always have a lead role, as they have the training, education, and experience to help direct all members of the care team. Successfully managing complex care requires physician involvement in many different areas.
• Definition and diagnosis. No one in the health care system is better equipped than the primary care physician to define and familiarize a new or worsening diagnosis to a patient. This includes the condition''s short and long-term consequences, recognition of early exacerbations, and most importantly, how to engage patients in managing their own illnesses.
• Coding/complications. The accurate coding of a patient's diagnosis and their complications feel like an administrative burden to physicians, but leaving it to others can lead to errors. ICD-10 codes are used to stratify a patient''s risk and identify those who need clinical interventions and outreach. Without accurate coding, it is impossible to identify your most complex patients. For example, if you don''t code a diabetic as having Ophthalmic complications, your care team won''t be focused on those patients in most need of Ophthalmology follow-up.
• Care coordination: Great care doesn't happen with primary care alone. You are in the best position to know who in your community of specialists communicates well, shares important information in a timely fashion, and gets the best clinical results. Defining a network of like-minded specialists will improve your ability to deliver the best outcomes for patients.
Know Your Patients
To manage your complex patient, you must be able to answer three basic questions:
• Who are my complex patients?
• What illnesses and complications do they have?
• Where have they been in the healthcare system?
In insurance speak - attribution, acuity, and utilization.
Attribution: Payers attribute patients to physicians based on the frequency and intensity of their primary care visits. In the simplest terms, if you see a patient more than any other primary care physician, the patient is likely to be attributed to you.
Attribution is important because payers measure the cost and quality of your services against national and local results based on your attributed patients. Complex patients disproportionately impact your cost and quality results.