AMDIS: Urgency for improving care coordination for complex patients

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BOSTON—The healthcare industry has a narrow window to accomplish the triple aim of better health, better outcomes and lower costs, said Claus Hamann, MD, MS, internist, geriatrician and informatician with consulting firm Accenture, speaking at the AMDIS Fall Symposium.

“We have to focus on the care of patients with complex illnesses. To succeed, we really need to embrace collaborative, coordinated care. That’s not an innovation but it turns out to be quite disruptive,” he said.

To achieve that, providers should adopt proven models into accountable care because accountable care provides the right environment for the triple aim.

A focus on complex patients is important not because that’s where the money is but because it is where the variation is, Hamann said. Meanwhile, dementia is a ‘sleeper’ condition that is expected to increase tenfold by 2050. Healthcare will be dealing with diabetes with dementia and leukemia with dementia. “We will need to think in those terms all the time. There is a lot of urgency here.”

Hamann cited CareMore, a model designed to offer high intensity management for the frailest 2 percent of the elderly population. The health system’s performance will increasingly depend on a high-functioning, team-based approach to care, he added.

Health IT faces several challenges in the post-acute and long term care setting. These areas function almost entirely on paper and fax and there is often high staff turnover. But, when it comes to avoiding penalties for readmissions, “the post-acute care sector is as responsible as the emergency department and the hospital. Having nursing homes collaborate with you is absolutely key. There are benefits that are very tangible.”