Do comorbidities sabotage CHF management efforts?

Ditch single solutions for integrated approach

Your new enrollee is a 67-year-old woman who lives alone three years after the death of her husband. Her medical history, spotted with emergency department visits and hospitalizations, suggests that her diabetes and CHF have been poorly managed. She is a lifelong smoker and has developed chronic obstructive pulmonary disease.

A candidate for three different disease management programs within your health plan, she complains that she’s being overwhelmed with more patient education materials than she can deal with or comprehend. As a result, none of the interventions tailored for her are working well, and the redundant care she and others like her are receiving is driving your organization’s costs through the roof.

As managed care organizations expand their disease management focus, such scenarios are growing increasingly common, says Catherine Hoffman, ScD, senior policy analyst at the Kaiser Family Foundation in Menlo Park, CA, and author of a recent study on the future of caring for the chronically ill. Indeed, chronic care managers are claiming now that comorbidities constitute the most troubling issue they face in light of an increasingly elderly patient population.

"We’ve got this tension between the need for more specialized care and also the need for more general oversight of people with complex chronic conditions," Hoffman says.

The disease management model is wonderful because it can maximize the care each health provider brings to patients, she says. "But counter to that is the fact that, with the aging of America, more of us are going to have chronic conditions. And since a good share of people with chronic conditions are going to have more than one, how can you really manage their care in these single disease solutions?" Hoffman asks.

Problems due to design flaws

In many ways, the problem of dealing with comorbidities has grown right along with disease management and stems largely from flaws in the design of early disease management programs, says Gary Slatko, MD, MBA, vice president of operations in the care management division at Glaxo Wellcome in Research Triangle Park, NC, a pharmaceutical company now seeking to expand its disease management offerings.

"The reality is that people don’t come with drug indications," Slatko says. "They come with combinations of conditions. And the initial pharmaceutical industry approach to this challenge was to design programs around specific diseases in areas where they had products and treatment indications."

Similarly, faced with the challenge of dealing with variations among and even within different delivery systems, disease management companies began marketing their programs as single disease solutions, says Richard E. Ward, MD, MBA, director of the Center for Clinical Effectiveness at Henry Ford Health System in Detroit. "Given the complexities they’ve had to deal with, you can hardly blame them for trying to come up with something that’s at least somewhat standardized," he says.

Another obstacle to effective management of CHF comorbidities is the traditional multidisciplinary clinic model that’s still in place at many health systems, Ward contends. "It’s a tested method, and it’s certainly one that patients understand," Ward says. "But sometimes it fails in dealing with the complexities of a patient’s case."

For example, a clinic model might be a good choice for some cardiac patients, whose health landscapes are dominated by their heart condition. "But if you’ve got a number of subtler conditions, you can’t use a method like that without running the risk of some confusion as far as who’s really coordinating care and carrying out all the integrative tasks," he maintains.

Even so, Ward notes that many medical specialists, including allergists, cardiologists, and rheumatologists continue to view the establishment of a disease-specific clinic as "the ultimate for their field. From their perspective, it revolves around them and their specialties and their specialties’ patients." At the same time, primary care providers often view primary care clinics as "the center of everything," he says. "Well, the real world involves some of both."

Ward says that a more effective approach is to view care in the context of an integrated network where, for example, an allergist has some organizing influence over a patient’s care but doesn’t take full responsibility for the patient. Similarly, the primary care physician and case manager have case finding and integrative responsibilities "but without having to view things completely in the context of a send-out, receive-back model," he says.

Ward adds that any sort of effective integration of care among disease managers within different disciplines will necessarily rely on an information system infrastructure capable of supporting a variety of different interventions. "Without the development of information technologies that cut across diseases, there’s never going to be any coordination across these disease entities," Ward says. "And that’s been conspicuously absent from the market."

"The hope would be that if, in fact, people with comorbidities hooked up with disease management groups for each of their diagnoses, there would be extremely well-integrated information and communication systems in place," says Hoffman. "But we have no history in the United States of being able to do that in health care. We just don’t. We don’t even have good communication between doctors’ offices and the hospitals they serve."

Focus on subprocesses

A second possible solution for the management of patients with comorbid conditions is to conceptualize the process of disease management as a large number of smaller subprocesses, says Patrice Spath, ART, consultant in health care quality and resource management at Brown-Spath & Associates in Forest Grove, OR.

"If the services that are offered relate to a particular part of the management of a disease rather than the whole thing, then you make it easier for someone else to take that integrative role and say, I want a piece of this, a piece of this, and a piece of that,’" says Ward. But, he cautions, it’s important not to take that advice too far. "Otherwise, you’re just going back to the whole situation disease management was trying to get away from, where there wasn’t any integration across the disease spectrum. It’s just a balancing act."

For more information about dealing with comorbidities, contact:

Richard E. Ward, MD, MBA, Director, Center for Clinical Effectiveness, Henry Ford Health System, One Ford Place, Detroit, MI 48202. Telephone: (313) 874-1882.

Catherine Hoffman, ScD, Senior Policy Analyst at the Kaiser Family Foundation, Menlo Park, CA. Telephone: (415) 854-9400.

Patrice Spath, ART, Consultant in Health Care Quality and Resource Management, Brown-Spath & Associates, Forest Grove, OR. Telephone: (503) 357-9185.

Gary H. Slatko, MD, MBA, Vice President of Operations, Care Management Division, Glaxo Wellcome, Five Moore Drive, P.O. Box 13398, Research Triangle Park, NC 27709. Telephone: (919) 848-2687.