Clive Fields, MD

As patient populations present with multiple co-morbidities and more complicated diseases, it takes a consistent and systematic approach to manage these patients for the best clinical results - an important step to succeed in value-based care. 

Once you've identified your complex patients, what diagnosis they have, and how they utilize the healthcare system, you can begin building processes that better manage a complex population. Let's focus on the diabetic patient and how we at my practice, Village Family Practice (VFP) in Houston, Texas use these strategies to achieve the best results.

First, we recognize that diabetics all have the same disease, but are not all are alike. Individual problems need individual attention. Second, we place the patient's primary care physician at the center of a team of health care professionals. Then, we think of medical interventions in three concentric rings around a patient:

• Care within the exam room.
• Services outside the exam room but within our clinic.
• Services within the greater community in which the patient lives.

One of our key strategies is making sure that every interaction between the patient and healthcare professionals contributes positively to success. Our nurses are trained in rooming guidelines that are gender, age, disease, and symptom specific. In the case of our diabetic patient, nurses are responsible for medication reconciliation, quality gap closure, immunizations updates, and ordering disease-specific labs - all before a physician enters the exam room. This allows the physician to focus on treatment and education, minimizing paperwork or record reviews. 

Within the practice, there is a suite of services that address the needs of diabetic patients:

 We partnered with Healthy Interactions to build an American Diabetes Association certified diabetes education program at each of our practice locations. Most hospital programs focus on insulin administration and basic information for newly diagnosed diabetics. Our patients are more typically Type 2 diabetics needing an understanding of diet, medication education, and a focus on the short- and long-term complications of poorly managed diabetes.

  Since 2013, Centers for Medicare & Medicaid Services (CMS) has compensated physicians for providing regular clinical outreach and coordinating patient care.  We have used this reimbursement to build and help pay for a team of care coordinators that proactively reach out to our complex diabetic patients, getting in front of their physical, emotional, cultural, and financial healthcare issues before they lead to emergency and inpatient care. 

 The screening we have the most difficulty with is diabetic eye exams. Many referrals to an eye professional are simply never completed. In 2015, we brought a simple fundoscopic camera into our two larger clinics and included an immediate referral as part of our rooming guidelines. Patient compliance has improved, and we have detected dozens of cases of early retinopathy.

 Even though we are a primary care group, we added the specialties of podiatry and endocrinology. Having these specialists under the same roof and on the same scheduling system improves patient access and compliance.

 In 2013, we added a point-of-service pharmacy to our practice.  VillageMD, our management services organization partner, helped us determine how to defray the investment costs of creating an onsite pharmacy. Our pharmacist can access a patient's medical record, meet regularly with our clinical staff, and has collaborative practice agreements with our physicians. The pharmacy team helps patients understand their medications and keeps physicians up-to-date on medication options.

We use data to identify care gaps, quality opportunities, and medical utilization.  Most importantly, we use data to measure ourselves. Our improved quality and cost results speak to the value of a primary care driven and patient centered approach to the complex patient.

Publicly available CMS data show that our practices’ Medicare population performs much better than Medicare patients nationally on diabetes care standard.

In addition, patients who complete the diabetes education program have an additional 15 percent reduction in their HgA1c levels Our patients also receive 10 percent more screenings for neuropathy and 15 percent more retinopathy exams than the national average for the Medicare population.

Total cost of care for our practices diabetes patients in the Medicare population was 20 percent lower ($12,828 versus $16,150) than the national average for the same population.

To successfully manage complex patients under value based contracts, you must focus on cost and quality outcomes. Most of the healthcare expense within an individual practice is driven by 20 percent of patients, and that's where the focus needs to be. Identifying who your patients are and what their risk acuity is improves your ability to change the way your patients utilize the healthcare system. Our practice has made investments in technology and care management teams to help us identify and manage our most complex patients. Regardless of your practice's capabilities, using every patient contact and each member of your team to maximize patient outcomes will help you succeed.

Managing complex populations doesn't have to be complicated, but it does require a consistent and proactive approach to keep patients at the center of the healthcare system.

 is president of the Village Family Practice and co-founder/chief medical officer at VillageMD.

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This final part of a two-part series focuses on providing proactive care and measuring the results of complex patients.

Provide Proactive Care with Complex Patients

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.

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.

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.

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.

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.

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.

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.

It's common to have complex patients who you frequently see attributed to you. But what about a complex patient who sees multiple specialists but sees you infrequently, and only for simple acute problems? Such patients, and all their associated quality gaps and specialty costs, are also being attributed to you.

Without having any opportunity to help manage their care, you are left to rely on specialists to provide a coordinated clinical experience and document quality and risk codes.  Just as important is the healthy patient who has limited contact with the healthcare system. This patient may find himself unattributed, even though he or she believes you are their physician. 
It sounds simple but the key to attribution is seeing your patients, both the sick and the healthy.

At my practice, Village Family Practice (VFP) in Houston, Texas we use the annual wellness visit (AWV), a high-intensity visit that focuses on precise coding to capture an accurate acuity level, screening tests to close gaps in care, and preventative services, as the visit that helps drive attribution. The AWVs on our most complex patients are conducted by physicians; those patients with less complex problems are scheduled with our nurse practitioners, physician assistants, and clinical pharmacists. 

Physicians have an average practice panel of 1,500 patients, with 20 percent (or 300) of those patients typically consuming the majority of health care resources in your practice. Can you name your 300 patients?

Knowing the acuity level of patients helps providers prioritize patients, making sure the most complex patients are seen more frequently and have access to the resources they need. Acuity levels are determined by risk acuity scores. The score is determined by a patient''s ICD-10 diagnosis, the more complex the diagnosis the higher the score and the higher the acuity.

To successfully manage a complex patient population, you have to know how patients are utilizing the healthcare system--when, where, and why patients have been seen, across the system, including primary care, specialty care, emergency department (ED) visits, and most importantly hospital admissions.

Claims data can provide a historical look back, but are often too old to be useful. Most of us get notifications of ED admits, hospital admissions, and specialty consults from our physician colleagues. Finding a way to make a note in your electronic medical record (EMR) of very simple utilization data such as ED visits can greatly improve identifying patients who need more attention.

Utilization and quality are most accurately measured by combining EMR and claims data. Doing so allows you to view utilization both inside and outside of your practice. Once only available to large groups, this data is now available through independent physician associations, management services organizations, health information exchanges, and practice management companies. 

is president of the Village Family Practice and co-founder/chief medical officer at VillageMD.

Nobody is better prepared to manage complex patients than their primary-care provider. Here's why.

Author | Clive Fields, MD

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