1. 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

2. 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?

3. 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

4. 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

5. 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!

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

7. 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?

8. 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

9. 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.

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

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

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

13. 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

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

15. 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

16. 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

17. 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.

18. 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

19. 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

20. 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

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

22. 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?

23. 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

24. 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!

25. 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.”

26. 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.”

27. 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.”

28. 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.”

29. Questions and comments?