Opinion: Study Will Not be the Final Word in Caring for Complex Patients

If a cancer research trial doesn’t find the cure, researchers don’t stop searching. For those of us who spend our lives and careers fighting to improve care for individuals with the most significant medical, social and behavioral health needs, a study that found disappointing results from a well-regarded model will not deter us, but only reinforce the power and necessity of our endeavor. 

Taking a look back to earlier this year, before the COVID-19 outbreak changed everything, the New England Journal of Medicine published an article on a randomized control trial run by J-PAL North America in partnership with the Camden Coalition of Healthcare Providers in New Jersey. The J-PAL study focused on the Camden Core Model, which “pairs interprofessional care management teams with individuals who have patterns of high hospital utilization, chronic medical conditions and complex social needs.” From 2014 to 2017, J-PAL measured the impact of Camden’s model by comparing the 180-day hospital readmission rates of a control group and an intervention group. 

The study showed similar readmission rates in both the control and intervention groups-a result that certainly fell short of the expectations of clinical leaders across the country who care for the so-called “super users” of the healthcare system. In short, the study showed, for one relatively small cohort of very complex patients, the intervention did not result in fewer return trips to the hospital. 

Disappointing, yes-but not devastating, and surely no reason to stop trying. The study, while certainly important, was merely one data point in the effort to improve care for patients most in need. It also failed to account for external social factors-transportation, food security, housing and more-that are integral to the assessment of comprehensive care for such populations.

Yet, to read the headlines the study generated, one would think the results were a complete disaster for the care model. Depending on which story one read, the Camden model either failed a big test, or the program was questioned, or it fizzled, or it poses a “cautionary tale.” These headlines distract from the main takeaway of the study: Effective care for complex populations must address social needs. This is a lesson that innovative organizations working with these patients have already discovered.

At Commonwealth Care Alliance in Massachusetts (CCA), we have long recognized that care coordination alone would not suffice to change the course of the care journey for individuals managing complex social and behavioral health challenges. If a patient is worried about where their next meal will come from, or whether they will be evicted, they are unlikely to adhere to their medication schedule, or attend a follow-up medical appointment. That understanding has pushed organizations like CCA, Camden, and many others across the U.S. to continually innovate, analyze the effect of those innovations, improve our capabilities, and refine care models that go far beyond what was considered in this study.

Effective care models for these “super users” now include things like specialized primary care and care coordination; home-based acute and urgent care; behavioral health treatment; crisis stabilization units; primary care clinics; social services; mobile clinical teams; emergency room diversion programs; and end-of-life palliative care. Care plans are carefully tailored, personalized, designed and coordinated to address individual social circumstances. This approach enables us to successfully improve health outcomes and patient experiences – qualities that were not and could not be measured in the Camden study.

In the few months since the study was published, these care models have continued to evolve to protect these “super users,” who are the most at-risk during the COVID-19 pandemic. For example, at CCA, we have conducted more than 250,000 virtual clinical engagements with patients and members, created a support fund to help members with the costs of urgent needs, launched interdisciplinary care teams to provide needed in-person care to people in their homes-including those who are COVID-19 positive-and significantly expanded our use of predictive analytics, remote patient monitoring and proactive voice technology.

While the results of this study are disappointing, they should not be disheartening. Finding limited effect in one care model in one time period is no different than a frustrating clinical trial of a new treatment for cancer or Alzheimer’s. As caregivers and as innovators, we refine our approach, we measure our success or failure, and we try again. 

The Camden study will hopefully be the first of many randomized control trials to come and will serve as an important waypoint in our collective journey to improve care and reduce costs for our nation’s most complex patients.

Christopher D. Palmieri is President and Chief Executive Officer of Commonwealth Care Alliance®, a not-for-profit, community-based healthcare organization focused on care coordination and delivery for high-cost, high-needs individuals.