Personalized care for complex lives: initial outcomes of a behaviorally-informed complex care intervention.

Background: 5% of patients account for the majority of healthcare spend, but standardized interventions for this complex population struggle to generate return on investment. The aim of this study is the development and proof of concept of an adaptive intervention to reduce cost and risk of readmission for medically high-risk individuals with any behavioral health diagnosis.

Methods: A behaviorally-oriented, personalized care service was delivered using a consultative, team-based approach including a physician, counselor, dietitian and social worker in collaboration with nurse care coordinators.

Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health.

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps.

A Path to Risk: Critical Elements of a Structured Approach.

Value-based care arrangements have been the cornerstone of accountable care for decades. Risk arrangements with government and commercial insurance plans are ubiquitous, with most contracts focusing on upside risk only, meaning payers reward providers for good performance without punishing them for poor performance on quality and cost. However, payers are increasingly moving into downside risk arrangements, bringing to mind global capitation in the 1990s wherein several health systems failed.

A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management.

Individuals with complex, chronic diseases represent 5% of the population but consume 50% of the costs of care. These patients have , characterized by multiple chronic physical health conditions paired with a combination of behavioral health issues and/or unmet social needs. Unlike for most health problems, the problems faced by individuals with complex lives cannot be broken down into simpler parts to be solved independent from 1 another.

A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population.

Health care systems have made concerted efforts to improve value for individuals with complex and chronic disease. Despite these efforts, this population (and the Medicaid population in particular) has been historically difficult to impact as many members are disproportionately impacted by social determinants of health that interfere with their ability to engage the health care system effectively. Transactional, solutions-based interventions to resolve barriers to care have been ineffective at either improving outcomes or reducing cost in the long term.

The Unrecognized Impact of Anxiety in Complex and Costly Patients.

Strategies to reduce suffering and expense for complex and costly patients have met with limited success. This may be due to both the ongoing dependence on transactional relationships and the failure to recognize anxiety spectrum disorders as a primary driver of medical complexity. The authors describe an emerging current of thought regarding a universal approach to the conceptualization of anxiety disorders and extend it for application to medical complexity.

Redesigning Kidney Disease Care to Improve Value Delivery.

This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment.

Integrating primary care into a community mental health center.

Our initiation of a reverse-integration practice model revealed numerous advantages and rewards, as well as many challenges, for which we found solutions.

A Program to Increase the Appropriate Use of Long-Acting Injectable Antipsychotic Medications in Community Settings.

Objective: The Multilevel Facilitation of Long-Acting Antipsychotic Medication Program (MAP) is a novel intervention to increase the appropriate use of long-acting injectable (LAI) antipsychotics in community mental health clinics. The authors investigated the feasibility of MAP, facilitators and barriers to use, and preliminary impact on LAI medication use.

Methods: Two clinics in Texas and two in Ohio serving 750 and 617 individuals with schizophrenia receiving oral antipsychotics, respectively, were asked to change clinical procedures for 1 year by using either the not receiving optimum benefit (NOB) checklist or the checklist plus MAP.

Eliminating Defects in Behavioral Health Treatment.

To improve care, clinicians should seek to eliminate defects in behavioral health systems. The proposed framework to eliminate defects has three parts: designing a vision for defect-free care, designing analytics to guide care delivery, and identifying and alleviating defects that impede expected outcomes. To shepherd this process, psychiatrists need to embrace the role of systems engineer.

Expanding the playing field: public and community psychiatry fellowship and beyond.

Fellowship training in public and community psychiatry has been shown to both extend career tenure and promote leadership attainment. While starting and sustaining a successful fellowship involves overcoming several hurdles, a successful fellowship can serve as a foundation for developing a viable academic division. Case Western Reserve University has redesigned and expanded its public and community psychiatry fellowship.