Systems thinking can help redefine chronic care approaches

Fixing the process, not the people

When we look at fixing systemic issues, many times, quality improvement initiatives address individual challenges but lay the solutions with fixing people, not the process. Taking a step back to look at the holistic picture of how those issues arise requires a different view. A Harvard Business Review article by members of the Institute for Healthcare Improvement articulates it perfectly: These approaches disproportionately focus on the people within the system, not the system itself. It says health leaders need to “recognize that there is no greater generator of dissatisfaction than working in a system not intentionally and carefully designed for success. It is simply not right to add the weight of improving healthcare’s outcomes… to the daily challenges of working in poorly designed systems.”

Chronic care presents an ideal use case to put these concepts into practice. Patients with chronic conditions initially enter the system from different access points, often primary care or an emergency room. As they move through the system and meet with multidisciplinary teams, how can a systems approach improve their care experience? Identifying opportunities to address the environment care teams are working within can better support their workflows, equip patients in their health journey, and mitigate costly acute health events.

Tactics to improve chronic care with systems thinking

So, what does this look like in practice? I recently spoke on a panel conversation for Becker’s Healthcare with two clinicians who have real boots-on-the-ground experience at Brown University Health and Allina Health Cancer Institute. We discussed a handful of ideas and strategies for systematically addressing chronic care for better outcomes and lower costs.

Use uniform, standardized, evidence-based care pathways for symptom management

Keeping patients out of the emergency room can be an identified goal to solve with systems thinking, and proactively managing patient care through pathways can help. Having the right triage protocols and workflows can help identify high-risk or high-need patients early on and reduce acute costs.

An article in the Journal of Oncology Practice identified how standardized clinical pathways can help reduce acute care and support in-home treatment. Using nursing phone triage, clinical pathways dedicated to symptom management included protocols for dehydration, diarrhea, insomnia, and delayed chemotherapy-induced nausea and vomiting. Over five years, the percentage of patients going to the emergency department from a clinical call decreased by 60% and reduced preventable hospitalizations due to Clostridium difficile infection by 50%.

Creating a compassionate, holistic care plan

I heard from both colleagues how their respective institutions are leveraging networks to support compassionate care plans for oncology patients. It’s so critical that organizations identify multidisciplinary teams to support not only the health needs but also psychological, spiritual, and end-of-life concerns for them and their caregivers.

At Allina Health, the oncology nursing team emphasizes comprehensive and holistic assessments to understand the patient’s goals for their care. They also assess social drivers, such as emotional and psychosocial needs, and identify any barriers to care, like transportation. They then put a care plan in place that’s tailored for them and achievable to help support adherence. The cancer institute has also recently bolstered its education and engagement strategies to help patients take ownership in learning about their health and care plans.

In geriatric oncology at Brown, they implemented a screening program and consult service to address additional health elements that impact that population, like comorbidities, polypharmacy, and general health frailty. This helps not only manage their cancer but also informs their care plans to reduce the occurrence of toxicities and eventual hospitalizations.

Technology can help with risk stratification to identify high-touch patients

These personalized care plans can be helpful in addressing patient needs and mitigating issues, but they also can be resource-intensive. One way to help mitigate costs is to systematically identify high-touch patients who are more likely to need those individualized, high-touch care plans and create a pathway for others who are at lower risk for acute needs.

There is navigation software that can help identify high-risk patients and then tailor interventions as needed to make sure high-touch resources are going to the right patients. When the University of Alabama at Birmingham built its Patient Care Connect program based on this concept for chronic patients, in the last 30 days of patients’ lives, the system lowered ED visits by 20% and hospitalizations by 7% by making sure the patients were getting the proper supportive care they needed.

With systems thinking, you can better identify trigger events that are causing systemic issues, anticipate ripple effects, and help the interventions be holistic and sustainable by considering the broader system. The third issue of the UpToDate^® Point of Care Report looks at how systems thinking can help support better team-based care through standardized clinical information. Download the report and consider how a systems approach can support your chronic care patient journey.