Maestro Needed: Please Apply!

In 2002 I started post-grad work at Rollins School of Public Health in Atlanta.   Amidst the post-911 chaos and bioterrorism threats, policymakers were desperately providing funding to address security and quell public fears. Because the money had to come from somewhere, funding for public health programs in chronic disease, infectious diseases and birth defects were slashed while the overall budgets for the NIH and CDC were significantly increased. I watched the CDC build a huge central facility next to my school and heard tales of the internal chaos from my fellow students who worked there. They saw a gargantuan influx of resources, but the end point—how to best spend that money to keep Americans safe—seemed elusive.

At the exact same time, I was working on an AHRQ-funded project to drive improvements in heart failure care across a large health system in the Midwest. The innovative program employed nurses to assist heart failure patients as they transitioned home from the hospital. Using a combination of coaching, monitoring, and social support, the nurses helped these patients better manage their own illnesses, and the work resulted in a significant decrease in their readmission rates. This “transition space” between hospital and home was as lonely for these patients, with as few resources, as the bioterrorism space was before the Anthrax scare.

Fourteen years later that same “transition space” looks like the newly finished CDC: bustling with people, resources and activities. Payment reform urges providers to address the trajectory of patient illnesses across the care continuum. The industry is inundated with care transitions coaches, care coordinators, community health workers—to name but a few. Budgets already facing a razor thin margin are expanding to hire this new work force. Even in more traditional space, new attention is being paid to keep watch over patients, from post-surgical care in bundled payment plans, to specialty disease clinics, to advanced or complex illness care. And all of this is in addition to longstanding community-based services such as home care.

The time spent recovering from acute episodes or managing chronic illness in the community—what was once “lost in space” to the healthcare workforce-- is now being adopted by virtually every type of provider and payer, from primary care to hospitals to social service agencies to the payers themselves. Of course, this is in addition to the myriad of calls a patient receives after transitioning home--“we hope that you were extremely satisfied with the care you received”—“just checking in to see how you’re doing, Mr. Brown.” In the midst of the silence, we have successfully created…cacophony!

If your community does not yet have a very busy transition space, hang on, because you will. And while all of these interactions are well intentioned, the frequent result is unfortunate, inevitable and highly predictable: “DON’T CALL ME AGAIN!”

To solve one very complex problem, we are in the midst of creating another. So, how best can we organize the transition space to provide appropriate, discrete, longitudinal services that address all three domains of the Triple Aim?

In this age of technology solutions, the answer seems both obvious and eminently easy. Let’s just create an algorithm of services available and a hierarchy of how they should be prioritized. Embed that algorithm into a computer and create a one-stop solution for the provider. One click allows the patient’s unique tumblers to fall into place behind the door—age, condition, payer, location—so that the exact and correct combination is chosen automatically. Perhaps we don’t have to understand post-acute services, just recognize when the need for those services exists. Point, click, done.

The issue with such a solution is that it comes to its own dispassionate conclusion in spite of patient choice or need or the unique set of variables making up that patient’s environment and circumstance. It is a blind prescription—or, to return to the analogy of music, an attempt to pick out a tune off a page when one cannot read music.

Such an algorithmic solution can also be difficult for providers who bear financial risk or benefit for these patients. In this world of accountability, we often believe that the only way we can successfully and efficiently manage these populations is to maintain control. “Weigh yourself every day, follow your diet, take your medicine” is just the first part of that control. The second part is that “Suzie down the hall” is going to be monitoring all of this for me. While there may be other options better suited to the patient, this investment and trust is real and a powerful contributor to creating new services in-house rather than reaching out to existing ones.

A few years ago I held a series of meetings where I brought the continuum of care providers and payers together. Our goal was to come to consensus on how services would be prioritized for individual patients. We all happily agreed to share the types of services we provided to specific patient populations. We effortlessly created joint principles for establishing a hierarchy to distribute those services most appropriately. However, when we applied those principles to the specific programs, our discord was immediate and immovable because every provider in the room completely believed that they were the logical and best first choice for their patients each and every time.

Of course, more germane to the issue is what is best for the patient as expressed by that patient. Ultimately, a point and click solution cannot work because it does not take into account the complexity of the patient’s needs, issues and desires. A one-stop technology solution is the “cookbook medicine” solution of the past, placing a rubber stamp sign-off on what has to be a human interaction.   We cannot help patients successfully address their myriad of issues without understanding the context of those issues: social complexity, financial duress, homelessness, mental health illness, physical abuse, substance abuse…the list is endless and its impact profound.

And so, it seems, we need to learn the music of the post-acute world. We need a Maestro to lift up the nuances in the notes so that the whole rings true for the people whom we serve everyday. This does not mean that we cannot digitalize the complexity of services offered, but rather that we must first clearly view the person before us and the barriers to health he or she faces. It is only when we are able to skillfully do this that we can start to find well-orchestrated solutions.

The fact of the matter is, the transition space is fundamentally more complex than the hospital because it is an uncontrolled environment. We cannot point and click our way to a solution—we have to diagnose and treat the root cause. This doesn’t mean that technology cannot be an essential and invaluable aid. What it does mean is that the caregiver-- with all the skill of a Maestro-- must first understand the “musical score” and its many nuances so that it is played with sensitivity, beauty and respect.

Ultimately, if we are going to get this right, we need to find a way to hear what is before us, and lift our batons.