The Center of Medicaid and Medicare Service continues to increase emphasis on care collaboration, ranging from chronic care management to the recent announcement from the US Surgeon General’s landmark report on alcohol, drug and health.

Research has demonstrated bidirectional links between mental disorders and chronic conditions. Depression and anxiety are heightening the risks towards hypertension and diabetes along with other mental disorders such as PTSD, drug addiction and alcoholism. Depression roughly doubles the risk for a new coronary heart disease event. Such interdependencies have limited solutions today because of the lack of a collaborative environment.

A detox center can only retain the patient for detoxification for a limited time. Without collaborating with other behavioral services, the patient will inevitably return to the same habit—either drug addiction or alcoholism. Depression can stem from a social environment or from a recently developed chronic condition.

The primary care provider will continue to address the chronic condition without the knowledge of what may actually feed into the patient’s chronic condition. It is yet another revolving door for the physical care environment. Such interdependency requires care collaborative environment between care providers, and information technology and information exchange offers potential to improve coordination.

[Image: Bloomberg]
[Image: Bloomberg]

A team-based care collaborative model uses a multidiscipline group of care providers supporting and implementing treatment, with the patient at the center. A bidirectional information flow is an absolute must to achieve this model.

Today, healthcare lacks the support of a closed-loop system, one that emphasizes a bidirectional flow of information. Healthcare is muddled with reactive care, instead of preventive, anticipated care. It is that lack of prevention and anticipation that have an adverse impact on the overall healthcare cost and patient outcomes. EHR and EMR systems are the main anchors of today’s health IT that offer promise in breaking this unproductive cycle.

However, there are two EHR components that are problematic—the boundary of the health organization and unidirectional systems. Health information exchanges address EHR limitations, with their capability to provide support across health organizations, but actually worsen the unidirectional character of the EHR. Neither EHRs or HIEs can address the requirements for a care collaborative model.

Hospital system CEOs and CIOs need to look at this issue carefully. This IT issue offers healthcare facilities the perfect opportunity to not only promote the care collaborative model, but offer a solution to resolving the bidirectional information flow problem and enable them to move forward with a new platform to achieve better patient outcomes, the goal of all healthcare facilities.

The objective is to improve patient outcomes, but how do you define a patient’s outcome?

Homeostasis is a biological term, referring to the stability, balance or equilibrium within the body. Homeostasis is the process of maintaining a constant internal environment by providing the body with what is needed to survive for the well being of the whole. While disorders (physical or mental) reflect the abnormal condition of the body, homeostasis is the normal, stable and well-being state.

Each disorder is well documented with what would be a normal condition or the state of homeostasis. This state of homeostasis also deviates based on race, demographics and, above all, the relationship with other existing disorders afflicting the patient. It is then noted that each patient outcome requires a personalized state of homeostasis.

The state of homeostasis should be used as the measure of a patient’s outcome, resulting from the care collaborative model addressing the integrated, coordinated care from multiple care providers.

The Health Collaborative Ecosystem is the delivery process that supports the care collaborative model, with the objective of bringing the patient to the state of homeostasis. This system would include all providers of health-related services to the chronically ill patient diagnosed with one or more of the designated chronic and debilitating diagnosis that utilize the most significant percentage of healthcare spending. Such a system would be:

  • Capable of integrating physical and mental care environments.
  • An integrated layer complementing (including EHR-agnostic) existing health IT infrastructures, supporting care activities beyond the brick and mortal walls of their facility or clinic.
  • Consensus among providers to standards of care and bidirectional information flow that encourages innovation, compliance with regulations, secures privacy and adopts a continuous process of improvements to better reach a patient’s state of homeostasis.

An ecosystem is best approach for a variety of reasons. It is a collective system, including a health IT solution and consulting guidance and support, for hospital operations to maximize the benefits of care collaboration, through efficiency and scalability of care providers’ bandwidth. It must include an auditable compliance component to provide crucial measurements and enforce quality guidelines for the model according to hospital and clinic management. The ecosystem also must include the ability to track and monitor progress towards the state of homeostasis for all attributes contributing the patient’s overall well being.

So how would this play out in a real-world care setting? For example, a 75-year-old patient may take a dozen medications to treat diabetes, high blood pressure, mild congestive heart failure and arthritis. After beginning to have trouble remembering to take the pills, the patient might visit her primary-care physician to discuss this and other worrisome developments, such as hip and knee pain, dizziness, low blood sugar and a recent fall. During the typical physician encounter, there is not enough time to address the patient’s myriad ailments. A patient may see several specialists, but no one talks to all providers about care, resulting in potential conflicting recommendations for treatment, or medications that could interact harmfully.

The care team for the above patient would potentially consists of: a primary care provider (high blood pressure and care coordinator), a cardiologist (congestion heart failure), an endocrinologist (diabetes), dietician (diabetes), a rheumatologist (arthritis), physical and/or occupational therapists (arthritis, falls, hip and knee pain), and a psychologist or a psychiatrist (depression).

The above case brings challenges to the healthcare system on multiple fronts:

  • More time from primary care providers with limited result outcomes due to the lack of collaboration with other care providers, specialists and community services.
  • Potential conflicting recommendations for treatment because of the lack of coordination and bidirectional medical information flows from multiple care providers and specialists.
  • The patient’s risk for complications, emergency visits and hospital stays significantly increases.
  • As conditions worsen, the patient develops symptoms for behavioral health conditions.

The solution for the above scenario is based on care management. The care manager would work with all care providers, manually “pulling and pushing” the patient’s medical conditions and updates to all involved care providers. However, implementing the care collaborative model has been error prone, costly and inefficient, CMS notes.

This is the challenge of a “revolving door care environment’ in addressing the need for integration between physical and behavioral health services. The Health Collaborative Ecosystem is the answer for such a challenge.

However, to support such a revolution, healthcare, as an industry, needs to have financial incentives. CMS is now encouraging a transformation through financial incentives.

With the Health Collaborative Ecosystem’s objective is to create a patient state of homeostasis, rural and community hospitals and clinics can accomplish multiple goals—they can better services to the community, better defined patient outcomes and open new avenues for health services with behavioral health and filling the revenue gap.

Donald Voltz, MD

Donald Voltz, MD

Donald Voltz, MD, is in the Department of Anesthesiology at Aultman Hospital, where he serves as Medical Director of the Main Operating Room.