title: Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations.
abstract: Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.
authors.affiliation: The Gehr Family Center for Implementation Science, Keck School of Medicine, University of Southern California, 2020 Zonal Ave., IRD 320, Los Angeles, CA, 90033, USA. mhochman@med.usc.edu.
authors.forename: Michael
authors.initials: M
authors.lastname: Hochman
authors.affiliation: Stanford University School of Medicine, Stanford, CA, USA.|The VA Palo Alto Health Care System, Menlo Park, CA, USA.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D006291:Health Policy; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D000071069:Multiple Chronic Conditions / Q000628:therapy; D010346:Patient Care Management / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D058996:Quality Improvement; D012959:Socioeconomic Factors; D014481:United States; D035862:Vulnerable Populations