Health care in the United States faces critical challenges despite tremendous developments in medical science and care delivery, such as biomedical discoveries, new approaches to health care financing, and the rise of digital technologies.1 Although health care spending in the United States accounts for almost 18% of our gross domestic product—a rate considerably higher than all peer countries2—10% of the US population report their health as either poor or only fair.3 Rates of preventable chronic conditions continue to rise, contributing to poor health and increasing health care costs, and evidence-based strategies for prevention and management are poorly applied throughout the health care system.1
About 5% of adults in the United States (almost 12 million people) report having 3 or more chronic conditions and a functional limitation that makes it difficult for them to carry out daily activities.4 They account for almost half of US health care spending.5 Described as “high-need, high-cost” (HNHC), these individuals comprise our most complex patient population—one that has many needs that can best be met by physical therapists and other rehabilitation professionals. The HNHC population is diverse, consisting of people who are “frail 65+,” people who have disabilities, people who have advanced life-threatening illness, and community-dwelling people of all ages. This population all too often receives ineffective care, such as unnecessary hospitalizations.6
The presence of a functional limitation among the HNHC population can substantially increase health care utilization, cost, and the likelihood of receiving poor quality of care. Average annual health care spending is nearly 3 times higher for adults with multiple chronic conditions and functional limitations compared with adults with multiple chronic conditions only ($21,021 vs $7,577).4 With their functional limitations, the HNHC group is twice as likely to visit the emergency room and 3 times more likely to be hospitalized than adults with multiple chronic conditions only. Managing functional limitations—the central expertise of rehabilitation professionals—is an important consideration in the overall management of the HNHC patient population's needs. As reported in this issue by Kadivar and colleagues,7 providing optimal discharge disposition and follow-up services could prevent unplanned hospital readmissions. These investigators report that the odds of 30-day readmissions were 3.78 times greater when a physical therapist was absent from the discharge team compared with the odds of 30-day readmissions when a physical therapist participated. Despite their qualifications, physical therapists are infrequently represented on the interdisciplinary team.
Through an exciting Vital Directions initiative,1 the National Academy of Medicine (NAM) (formerly the Institute of Medicine) is assembling authoritative advice from the nation's foremost innovators to address the health needs of the United States, including the HNHC population. As Blumenthal and colleagues6 noted in their NAM discussion paper, the Affordable Care Act “offers an array of incentives and tools for pilot testing and refining alternative delivery and payment models, and many states and private payers have been experimenting with new approaches.” Increasingly, the shift toward value-based, population-oriented care encourages the participation of multiple providers, including physical therapists, to provide appropriate, high-quality care and to achieve improved outcomes in the HNHC population.
A number of care management models targeting the HNHC patient population have had promising results in improving quality of care, quality of life, and reducing unnecessary hospitalizations and costs.8 Existing evidence, though incomplete, indicates several common attributes seen in care management models that have proved to be successful, including9,10:
Close targeting of patients who are most likely to benefit from the services
Comprehensive assessment of patient needs
Specially trained care managers who facilitate coordination and communication among patient, family, and the care team
Interdisciplinary teamwork
Ability to manage patients' care across settings
However, because of the ongoing misalignment of health care resources in this country, widespread adoption of these programs has been retarded.6
Given that the HNHC population is certain to grow in the coming decades, it is imperative that physical therapists and other rehabilitation professionals support the adoption of innovative strategies such as comprehensive care management for this population.
- © 2016 American Physical Therapy Association
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