December 11, 2020

For many people, it can be difficult to manage one chronic health condition. For those who are coping with 2 or more ongoing health concerns, as well as depression, anxiety, substance use, or a lack of financial resources or social support, it can be absolutely daunting. Throughout the country, health systems are exploring ways to improve outcomes for this group of patients — known as the medically complex — who are more likely to sustain high medical costs, frequently use the emergency department, or need to be hospitalized.

photo of Richard Grant, MD, MPH

Richard Grant, MD, MPH

To gain insight into these patients, Richard Grant, MD, MPH, a research scientist at the Kaiser Permanente Northern California Division of Research, studied the characteristics, health use, and outcomes of 104,869 medically complex KP Northern California members. The research, which Grant calls “hypothesis generating,” was co-authored with colleagues at the Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Colorado Institute for Health Research, and University of California, Berkeley, and published December 11 in JAMA Network Open.

Using advanced analytic techniques, and working with the KP Northern California Complex Needs Advisory Council (CNAC), a group of clinicians and operational leaders who are advisors on complex needs care, the research team identified 7 distinct types of medically complex patients: the high acuity (very sick); older adults with cardiovascular complications; older frail adults; adults managing pain; adults with a psychiatric illness; adults undergoing cancer treatment; and adults less engaged in their own care.

photo of Anna Bavykina, MD, hospital specialist, The Permanente Medical Group.

Anna Bavykina, MD

Anna Bavykina, MD, a hospital specialist with The Permanente Medical Group and a CNAC member who consulted on the study, knows each of these types of patients well. Committed to improving care for the medically complex, she recently established a multidisciplinary team of physicians, nurses, pharmacists, and social workers trained to provide the type of needs-based care these patients require.

We spoke with Drs. Grant and Bavykina about the new study and the importance of identifying ways to improve the health outcomes of this growing patient population.

Q: What group of patients were the focus of this study?

Dr. Grant: We studied the 104,869 KP Northern California members who were the most complex. All of the patients in our study had 2 or more chronic conditions, had high medical needs and high social needs, and had recent hospitalizations. They are the tip of the iceberg — the top 3.3% of our 4.5 million members — who require the most care.

Q: Why is it important to study this group of patients?

Dr. Bavykina: Complex patients don’t only have a combination of different medical conditions. They also have psychosocial factors, like financial challenges or a lack of social support, that make them unique and that make their health care difficult to manage. For a physician, there are significant challenges in trying to address these patients’ medical needs while also helping the patients and their caregivers navigate the logistics of everyday life. This new study has a predictive element which allows us to think about which patients are at risk of decline and what we can do to mitigate that risk.

Q: How did you identify the 7 different types of medically complex patients?

Dr. Grant: The 3.3% of patients who are the tip of the iceberg are all medically complex but they are not all alike. If you want to design different models of care for medically complex patients, you have to understand what types of patients are part of this group. First, we used an advanced analytic technique, called clustering, that sorted the patients into 7 distinct groups. Next, we looked at the patients in each group and developed descriptions of what they had in common. Then, the members of CNAC reviewed these data profiles and made connections between these profiles and the patients they care for and put it into clinical context. Having these distinct profiles allows you to think about the types of care strategies each group might need.

Q: What are the next steps?

Dr. Grant: This project is hypothesis generating, and the insights can be used by CNAC and others who are responsible for complex care in Northern California to think about how to design programs for our medically complex patients. For example, we showed in this study that these 7 groups of patients had very different outcomes, hospitalization rates, and death rates. That is valuable information for leaders and care system planners.

Dr. Bavykina: Managing patients with complex medical needs is a well-recognized national problem. To date, nobody has developed the perfect solution. My personal passion is to put a model of care coordination in place to support complex needs patients. I think that Kaiser Permanente, because of its integrated care system, has the best potential to create a solution that will be the gold standard not only for our organization but for the nation.

Editor’s Note: This research was supported by Kaiser Permanente’s Garfield Memorial Fund, under its Complex Care Collaboration: Research, Operations and Leadership (CORAL) portfolio.

Co-authors include Jodi McCloskey, MPH, and Megan Hatfield, MPH, of the Division of Research; Chris Kennedy, PhD, of the Division of Research and the University of California, Berkeley; James D. Ralston, MD, MPH, of the Kaiser Permanente Washington Health Research Institute; and Elizabeth Bayliss, MD, MSPH, of the Institute for Health Research, Kaiser Permanente Colorado.

This story originally appeared in Division of Research Spotlight