Care of Underserved Patients Using Complexity Theory to Enhance Patient Care and Resident Capability University of Washington Department of Family Medicine Jaqueline Raetz, MD Jane Huntington, MD Carol Charles, MSW Valerie Ross, MS Kavitha Chunchu, MD

Introduction What are the challenges in teaching residents to care for underserved patients? We need a vocabulary We need to teach and model team care We need better communication skills We need to know community resources What are some curricular solutions?

Case Presentation SD is a 60 year old woman with multiple medical and social problems: Type 2 diabetes, asthma, bladder cancer, GERD, sarcoidosis, obstructive sleep apnea, and a history of falls Lives alone on disability assistance and calls the clinic frequently Limited family involvement

Case Presentation (cont’d) Care from multiple specialists: Family medicine, pulmonology, rheumatology, psychiatry, rehab medicine, general surgery, and gastroenterology Three inpatient admissions in the last three months More than 20 medications New family physician: Dr. Chunchu

Challenges in the care of this patient: It is hard to articulate why it feels overwhelming Lack of useful descriptors Negative phrases often come to mind Too many problems for one person to ‘fix’ Communication between the doctor and the patient often seems to miss the point Difficult to find community resources All of this creates stress!

CHALLENGE #1: SOLUTION: We need ways to understand and analyze what makes a patient complex. SOLUTION: Teach residents about the Minnesota Complexity Assessment.

Complexity theory “Most difficult patients started out merely as complex.” CJ Peek, PhD, Minnesota What makes a system complex? Not always possible to predict actions Actions are interconnected and change the context for other actions Uncertainty is unavoidable A useful metaphor for health?

Minnesota Complexity Assessment Method Understand the ways that a patient is complex Develop a shared vocabulary to describe complexity Move beyond description to levels of action

Five dimensions of complexity 1. Symptom severity and diagnostic challenge 2. Distress and readiness to engage 3. Social safety, support, participation 4. Health system intensity and relationships 5. Socio-cultural status Credits to Stiefel and Huyse, and Peek, Baird, Coleman et al.

CHALLENGE #2: SOLUTION: Caring for a complex patient alone is overwhelming. SOLUTION: Create opportunities for residents to work with interdisciplinary teams. 10

Goals of Team Care Strive to be patient-centered Understand team roles Develop leadership skills Prevent sense of isolation Appreciate longitudinal aspects of care

Opportunities for Team Care The “Supervisit” Geriatric Assessment Clinic Interdisciplinary Team Conference

CHALLENGE #3: SOLUTION: Communication between a complex patient and the doctor can be difficult. SOLUTION: Teach residents concrete skills in patient-centered communication and behavior change. 13

Communication & Complexity Goals Focus on Patient-Centered Interviewing and Motivational Interviewing Skills Model Collaboration Learn from each other Integrate teaching and practice

Complexity Complexity and Communication Bio-Psycho. Symptoms Build the Relationship Assess Patient’s Perspective Reach Common Ground Ask about importance and confidence Roll with Resistance Assess barriers to change Support self-efficacy Listen reflectively OARS Set the Agenda Complexity and Communication Complexity Bio-Psycho. Symptoms Distress & Engagement Socio-Cultural Social Resources Systems Express Empathy Psychological Disempowerment Trauma Trust Isolation Cultural Differences Immigration Language Belief systems Chronic Disease Addictions Medication Adherence Lifestyle Change

Model Collaboration Teaching Models Integrate Teaching& Practice Physician And Behavioral Faculty Co-teach Teaching Models Tutorial sessions Observation Form Direct observation (2x2) Paired Observation Video review Integrate Teaching& Practice Articulate Skills Practice Skills Reflection

Communication & Complexity How is it working? Patient-centeredness becoming more part of the culture. Motivational Interviewing skills more difficult to integrate into the culture currently.

CHALLENGE #4: SOLUTION: Residents don’t know enough about community resources available to patients. SOLUTION: Provide residents with direct experience in a variety of community settings. 18

Community Resources: Beyond the Clinic Walls Community resources are part of the complex patient’s care team. Residents learn: How to connect a patient What a patient experiences when using the resource What are the barriers How to collaborate

Community Resource Experiences Creating a worthwhile experience Interest surveys Introductory visit and “Sales Pitch” Selecting the sites: Relevant and interesting Motivated to teach and flexible Preparing the site staff and the resident

Community Resource Experiences Evaluating the experience Post-visit survey What was learned? Recommendations? Prompt follow up with community resource

Goal: A Sustainable Program Continue to build relationships Develop a small roster of “most reliable” resources Unanswered questions: What can we offer the community resources in return? How can we include community resources as team members?

Case presentation: conclusion Understand how this patient is complex Develop a care plan with the team Improve communication during more ‘organized’ visits Involve appropriate community resources

Measures of success Better patient care Understand the complexity of the illness and the social context, team care plan, effective communication, and links to community resources. Enhanced confidence in caring for complex patients Residents who are resilient, confident leaders, and committed patient advocates!

Resident comments on the curriculum: “I would know that a patient was complex, but this rotation helped me organize the issues and my thoughts, to identify what are the factors that comprise complexity.”

Resident comments on the curriculum: “The extra time in clinic allowed me to start feeling like I was building a team.” “I came away with a little more confidence in finding a resource for a patient, knowing whom to ask or call. I feel like I started to create a network of people I can call.”

Resident comments on the curriculum: “ I learned more about the general structure of child mental health and protective services. I now have a grasp of what actually happens when I make a CPS referral or try to get a kid into mental health services.” “It is refreshing to be in a community where we don’t have to solve all the problems alone.”

Resident comments on the curriculum: “There are resources out there for people who want help. There are ways to help people stay at home and be functional members of society.” “My favorite: the presentation and lunch with the Vietnamese Seniors group. It was fun and I learned a lot.”

Questions and comments?