They are relatively small in number, but they are the largest consumers of healthcare services. Medically complex patients, with multiple chronic conditions that can make clear treatment pathways difficult to identify, are a population that has not been studied extensively. Recent research, however, begins to identify distinct cohorts and establishes a framework for treatment and care management.

The 7 types of medically complex patients and what they need from home care

A quantitative 2020 Health Informatics study identified 7 main cohorts from a sample group of 104,000+ northern California Kaiser Permanente members with medically complex conditions.

We believe this type of segmentation is significant because 1. Large scale studies of medically complex patients are uncommon, and 2. It provides a lens through which clients can evaluate home-based treatment.

The segments the study identified may be useful to Elder Law attorneys or providers who work with these segments of patients. The percentages indicate the fraction of the total patient population studied:

7 Categories of Medical Complexity

medical complexity chart

A quantitative study of 100,000+ patients with medically complex conditions reveal 7 distinct cohorts.

1. Less clinically engaged patients (27%).

This segment may have multiple comorbidities but less need for care, perhaps because their conditions have not worsened, or they simply are reluctant to seek treatment. In terms of home care, they require engagement and education to keep them as healthy as possible.

2. Older patients with cardiovascular complications (15.9%).

This group needs disease management from professionals experienced in geriatric and cardiovascular care. “When we deal with elderly heart patients,” said Nira Moreno, a SeniorBridge Clinical Manager. “Many times it’s congestive heart failure, atrial fibrillation, or another condition….so we need to create a plan that each patient needs while being cared for at home. This includes diuretics and treatment of mental health conditions that often come with heart problems, specifically depression.”

3. Frail elderly (12.5%).

This category of medically complex patient has the highest degree of mortality, demanding experienced geriatric care. Depending on the condition, home care measures for this type of medically complex patient may include monitoring, guided physical activity, and safety interventions to prevent falls.

4. Pain management patients (12.3%).

Chronic pain patients have high healthcare utilization rates and, often, mental/behavioral health issues. Home care can support their condition with medication management and non-medication interventions that can reduce pain, such as exercise.

5. Psychiatric illness patients (12.0%).

These patients have mental illnesses that may be complicated by pain, substance use, social isolation, and alienation. They need coordination between medical, social, and mental health care. Depression is a dominant condition in this category – and evidence shows that well-coordinated care, education, and self-management can significantly improve symptoms

6. Highest acuity patients (9.4%).

These are the neediest patients with the highest healthcare utilization, requiring high levels of care coordination. This is where medically directed home care, under an RN’s supervision, can act as an extension of the patient’s medical team for monitoring, reporting, medication management, managing transitions, and other services.

7. Active cancer treatment patients (7.6%).

This group is in the process of navigating cancer treatment, requiring pain and medication management. They need intensive care and, in the words of Abena Agyemang-Panbour, a SeniorBridge home health aide, “When we start home care for a cancer patient, we plan safety measures, medications, activity, hygiene, and we do daily reports. We need to be an extension of the eyes and ears of the oncology team.”

“Each clinical profile,” the Health Informatics study concluded, “suggested a distinct collaborative care strategy to optimize management.”

The implications for medically directed home care are clear: Home care providers will need to be highly adaptive, because one size of care will clearly not fit all medically complex conditions.

The integrated care management model by SeniorBridge

Home care services vary widely in the services they provide.

SeniorBridge offers an integrated care management practice model that involves two components:

  1. Clinical care (under the direction of an RNCM/Registered Nurse Care Manager) supported by a Social Worker and a team of caregivers, based on patient’s needs and
  2. A portfolio of home care services and geriatric care management in such areas as nutrition, caregiver education, benefit coordination, transportation, and coordination with discharge planners, physicians, pharmacy, home health agencies, and care managers.

NOTE: We have full COVID-19 safety protocols in place to keep clients, families and associates safe.

For more information on medically directed home care, contact SeniorBridge.

Sources consulted:
JAMA/Health Informatics (2020)
Canadian Medical Association Journal (2018)

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