Publications

Who owns the patient in an integrated care model?

Share this story

Share this story

COPD care teams are comprised of a multitude of disciplines, across a multitude of locations. Each member of the team plays a vital role in patient management.

 

But who is ultimately responsible for the patient?

 

When patients get sick, whom should they call? Who initiates the palliative care discussion? Who should be the patient advocate throughout the complex COPD care journey?

 

The truth is, it can be any team member. But what works best – and how do you choose?

 

Read our insider insights on patient attribution in an ever-changing healthcare landscape.

Individual treater owning patient care

 

Traditionally, the ownership model has favored an individual care team member.

 

Based on numerous insider insights, the choice is often the PCP. The PCP is the one most likely to see the patient on a regular, non-emergency basis. Ownership can also be the domain of subspecialists who periodically see patients about more specific mat-ters.

Individual treater owning patient care

 

Traditionally, the ownership model has favored an individual care team member.

 

Based on numerous insider insights, the choice is often the PCP. The PCP is the one most likely to see the patient on a regular, non-emergency basis. Ownership can also be the domain of subspecialists who periodically see patients about more specific mat-ters.

 

In many cases, however, the COPD navigator takes ownership. He or she manages the longitudinal process, and is well suited to advocate for the patient at every step. The navigator, says Brad Drummond, “becomes the center of the wheel, with all the spokes being the different providers.”

 

But no single right answer applies to all patients. “A good rule is to take your cue from the patient,” says Drummond. When possible, give them a voice and a degree of own-ership over their care by letting them choose. Whether they choose the PCP or some-one else, the choice is highly personal.

Contributors

Bobbie V. Kumar, MD, MBA, FAAFP

Bobbie V. Kumar, MD, MBA, FAAFP

Medical Director, Swedish Edmonds Urgent Care

Director, Complex Care Management for Vituity

Kimberly Palczynski, RRT

Kimberly Palczynski, RRT

RT COPD Navigator

Inova Health

M. Bradley Drummond, MD, MHS

M. Bradley Drummond, MD, MHS

Clinical Associate Professor
University of North Carolina School of Medicine’s Division of Pulmonary Diseases and Critical Care Medicine
Amy Shaheen, MD, MSc

Amy Shaheen, MD, MSc

Professor of Medicine, Division of General Medicine and Clinical Epidemiology, UNC
Director of Population Health Services, UNC School of Medicine

In many cases, however, the COPD navigator takes ownership. He or she manages the longitudinal process, and is well suited to advocate for the patient at every step. The navigator, says Brad Drummond, “becomes the center of the wheel, with all the spokes being the different providers.”

 

But no single right answer applies to all patients. “A good rule is to take your cue from the patient,” says Drummond. When possible, give them a voice and a degree of own-ership over their care by letting them choose. Whether they choose the PCP or some-one else, the choice is highly personal.

Individual treater owning patient care

 

Traditionally, the ownership model has favored an individual care team member.

 

Based on numerous insider insights, the choice is often the PCP. The PCP is the one most likely to see the patient on a regular, non-emergency basis. Ownership can also be the domain of subspecialists who periodically see patients about more specific mat-ters.

 

In many cases, however, the COPD navigator takes ownership. He or she manages the longitudinal process, and is well suited to advocate for the patient at every step. The navigator, says Brad Drummond, “becomes the center of the wheel, with all the spokes being the different providers.”

 

But no single right answer applies to all patients. “A good rule is to take your cue from the patient,” says Drummond. When possible, give them a voice and a degree of own-ership over their care by letting them choose. Whether they choose the PCP or some-one else, the choice is highly personal.

Our approach has been to try to understand from the patient's perspective what they value. We see plenty of patients who have a wonderful relationship with their primary care provider.”

M. Brad Drummond, MD, MHS

Clinical Associate Professor

University of North Carolina School of Medicine’s Division

of Pulmonary Diseases and Critical Care Medicine

Driving patient ownership forward

 

Individual owners have proven effective. Yet as care moves toward an integrated model, is the forward-thinking solution a team-based ownership model? Many of our insiders say yes.

Treatment team owning patient care

 

Because seamless integration and collaboration drive better care (and support a reduc-tion in COPD readmissions), team-based ownership models are increasingly gaining favor. 

Growing support 

 

Rationale for care providers to share in the ownership of a patient case

  • Optimal care delivery requires cross-functional collaboration
  • Input on patient care comes from all at different times
  • Stakeholders across settings are expected to unify as a team around each patient
In my practice, we had a team-based model. We had a physician with a medical assis-tant, a patient service coordinator, a nurse, and a pharmacist. It worked so well because we had input from key players that helped identify the barriers that patients and care teams are facing.” 

Bobbie Kumar, MD, MBA, FAAFP 

Medical Director, Swedish Edmonds Urgent Care

Director, Complex Care Management for Vituity

New ops and challenged video
Well, I think it's provocative in that attribution—which I think is really the issue—who is this patient attributed to? And who does the patient attribute themselves to, right? And we have as a health system struggled with that. We figured out primary care attribution. So these are your patients as a primary care doctor. We're working on subspecialty at-tribution now. So we are saying, we need to be able to say, oncologist, who are all your patients, as well as pulmonologist, who are all of your patients? But then I think we're coming into a team attribution. And I think it has to be that way. That as a team, hey, these are all of your patients, team, and maybe we'll start comparing teams, instead of just individual providers. How is your team functioning? These are your measures as a team, and I think we're coming to that right now. It's kind of an individual and the healthcare system, but it's going to have to come somewhere. It's going to have to fall off somewhere in the middle. And it always comes down to oper-ationalizing. How do you operationalize those team measures? But I think we're getting there, and once we figure out subspecialty attributions, then we'll be able to start narrow-ing it down and coming up with those measures and how we follow those patients.”

Amy Shaheen, MD MSc Medicine Professor, 

Division of General Medicine and Clinical Epidemiology, UNC

Director of Population Health Services, University of

North Carolina School of Medi-cine

Data you can’t ignore

Findings from the Integrated COPD Care Initiative

A 2017 pilot program designed to increase visibility into patient-centric management in post-acute care. Care teams deployed evidence-based care strategies, pathways and processes, which were jointly owned by multidisciplinary providers (>890 patients):

  • Care-transition management
  • Ongoing homecare from RTs
  • Care coordination
  • Patient engagement

Key results1:

80% Reduction
In 30-day COPD readmissions
$1.3 million saved
70% Reduction
In 30-day COPD readmissions
$4.4 million saved

Sharing ownership starts with sharing information

 

If HCP’s aren’t accessing data and information generated by other treaters, effective collaboration is impossible.

Key issues of disconnected care teams

 

  • Lack of awareness of who did what (instructions, counseling, tests, data interpretation, etc.)
  • Unclear roles and responsibilities
  • Low agreement on treatment goals
  • Lack of effective patient education
  • Under-informed homecare teams
  • Low integration with inpatient care team

Impact

 

  • Patients and care issues slip through the cracks
  • Patients get inconsistent direction
  • HCP’s waste resources on duplicate efforts

Ultimate consequence: Increased risk of patient readmission

The unique challenges of small hospitals
50% icon

Smaller hospitals need to become part of a bigger vision of attribution, says Amy Shaheen, because they often have fewer resources, are in remote locations, and lack integration with larger networks.

 

This is a larger issue that needs to be managed aggressively, as integration is only effective if it is universal.

I think those smaller hospitals will have to become part of a bigger system, so that you can dialogue risks and bring in resources to help.”

Amy Shaheen, MD MSc Medicine Professor, 

Division of General Medicine and Clinical Epidemiology, UNC

Director of Population Health Services, University of

North Carolina School of Medi-cine

Integrated data sharing video
And how is the information always shared? We have a lot of physicians groups that are not part of the global EMR of the local hospitals. So when you are talking about a care team, how do we need to disseminate this information? How do we need to share better? I think that's another question to be asked. It's great to have it on the EMR, but if we are not all part of that, what do we do about that? About integrating the communication? There's no short-term answer on that.”

Kimberly Palczynski, RRT

RT COPD Navigator

Inova Health

Whoever owns the patient, be a champion

 

Be a cheerleader. Be an optimist. Treating COPD is hard, but living with it is even harder. Our insiders emphasize that when something goes right, celebrate.  “Recognition and encouragement are really important,” says Kumar,  “not just to the ego, but to also propel to continue down that path.”

In my practice, we had a team-based model. We had a physician with a medical assis-tant, a patient service coordinator, a nurse, and a pharmacist. It worked so well because we had input from key players that helped identify the barriers that patients and care teams are facing.” 

Bobbie Kumar, MD, MBA, FAAFP 

Medical Director, Swedish Edmonds Urgent Care

Director, Complex Care Management for Vituity

Email icon

Register now for exclusive monthly content like this delivered directly to your inbox

Contact information

* This field is mandatory
*

Contact details

*
*
*

Company details

*
*
Please Note: To receive the COPD insider newsletter the opt-in box must be selected.

Further reading

Link icon

COPD insider

References

1. Koninklijke Philips N.V. The Integrated COPD Care Initiative. 2018. https://www.usa.philips.com/c-dam/b2bhc/master/education-resources/copd-insider/common/alabama-paper/the-integrated-copd-care-intitative-copd-insider.pdf. Accessed June 19, 2019.

All content on this site is for informational and educational purposes only and is not a substitute for medical advice of your doctor or other health care professional. Always seek the advice of your physician or other health care provider with any questions you may have about any medical condition.  Refer to the Terms of Use for additional information.