by Allison Verdoorn
Designer researcher, Mayo Clinic Center for Innovation
Meet Susan and John. They are an active retired couple who enjoys traveling and visiting their grandchildren. John has multiple chronic health conditions including diabetes, high blood pressure and arthritis. Susan serves as John’s primary care giver and manages his medications and health conditions. The amount of work they must do to deal with John’s medical conditions is in balance with their capacity to do that work and achieve their larger goals.
In the Minimally Disruptive Medicine care model, John is assigned a Care Navigator, Frank, because of his multiple chronic conditions. Frank works with Susan and John on a frequent basis both by phone and in person to address any issues John might have either socially or medically. Frank is especially interested in any goals the couple has like traveling and losing weight and takes care to make sure any care plan is in line with the goals. Frank has access to a database of social service connections and is a member of John’s health care team so he is able to relay relevant information back and forth from John and Susan to John’s care team.
John suffers a stroke that hospitalizes him.
In the traditional medical model, John is seen by multiple specialists, each with different plans of care, diets and medications. Often these visits take place when Susan is not able to be present and the couple is left to reconcile all of the information they were given when John is released from the hospital. While his capacity has been reduce by illness his workload has increased with new diets, medications and plans.
In the Minimally Disruptive Medicine model John is cared for by a care team that includes physicians, dietitians, pharmacists, social workers, nurses, a care manager and care navigator. This care team consults carefully with specialists to ensure that a cohesive plan of care that aligns with John’s goals and work capacity balance is developed.
A care manager, Lucy, works with Frank, the care navigator, to ensure that the clinical goals of the care team work with and not against John and Susan’s goals and desires. The care manager serves as a counterpart to the care navigator as a liaison to the clinical team.
John is released from the hospital.
In the traditional medical model, John is sent home with a confusing dismissal summary, multiple new medications, conflicting diet plans, and two different rehab programs. John and Susan are unsure who to contact for follow up questions and instead try to make due as best they can with the information they have. Both John and Susan’s work to care for John has been increased while John’s capacity has been greatly reduced due to his illness.
In the Minimally Disruptive Medicine model John and Susan leave the hospital with a care plan that was discussed with them before leaving. The care plan is sensitive to the goals John and Susan are striving towards and includes contact information for their care team. John and Susan can call Frank with questions and concerns and Frank provides them not only with clarification but also community resource connections. Frank reports information directly to Lucy who is able to relay updates to the care team on a regular basis. Frank pays special attention to the couple’s work capacity balance.
In the traditional medical model, John’s health continues to decline and the stress of the situation and caring for her spouse begins to affect Susan’s health. The work she must do for John is a huge burden for her.
Susan feels she is becoming depressed and is no longer able to function at the level she had before the hospitalization. Because of this Susan’s capacity to do the increased work is reduced.
As Susan falls into a depression her ability to care for John is reduced and John’s health declines further.
With few resources, John and Susan continue to manage their declining health on their own.
In the Minimally Disruptive Medicine care model the care team continues to meet regularly even after John’s release from the hospital.
Physicians, nurses, care managers, care navigators, pharmacists, social workers and dietitians work together to make sure the plan of care that is developed reduces the amount of work the couple must do and increases their capacity to do it.
When specialty consults are necessary, the team reaches out to the relevant specialist and then brings the recommendations back to the larger group to ensure they are inline with the larger plan.
The team utilizes a dashboard to allow for an accurate understanding of the John and Susan’s work and capacity levels.
In the traditional medical model, John’s capacity continues to decline as his conditions are not well managed. Additionally his work has not been reduce and has in fact increase now that Susan is struggling with problems of her own.
The traditional medical model has placed John and Susan in a seemingly never ending loop that continues to add work to their lives while providing no additional capacity. John will struggle to improve over time and will likely continue to have expensive hospitalizations.
In the Minimally Disruptive care model John and Susan’s work and capacity balance is carefully monitored by their care team.
The care team develops care plans that help the couple
14 thoughts on “Minimally Disruptive Medicine comes alive!”
Medicina mínimamente perturbadora
(Hi this is an interesting concept it would be great for an individual like myself, 45 year old female who lives alone. I have multiple medical problems and I live alone. Currently I have 13+ doctors that I have to see as well as a nutritionist. It is hard for me to keep up with all the different doctors and follow up with them. I have also had multiple surgeries (12) in the last 27 months!
Great to hear that this approach to health care is being talked about in broader circles. South Central Foundation in Alaska has been doing this for a number of years.
How are your outcomes? Patient satisfaction? Hate to use the word but ‘compliance’ of chronic disease patients? This really seems to make sense.
Sounds like common sense.
sounds like something that should really be in place to offer the best care already… shouldn’t it be the care we expect?!?
The care team develops care plans that help the couple… The plan of care was not IDed. I deal with this on a daily basis. Add helping services, but at what out-of-pocket cost? Change in living arrangements for John, or both — how would that play out, and cost? Day activities / care — transportation, cost? John is feeling more depressed, with good reason, if he cannot move about, do IADLs, or participate in life like he used to… treat him with an antidepressant? Can the Care Team give back to John his abilities before his stroke, his pain free joints before arthritis, the couple’s financial stability and security, his Quality of Life according to his values? I am waiting to hear what the Minimally Disruptive Medicine Care Team can do, will do for John and Susan that is different than the Traditional Model, in the reality of economic recession, social & community services cut to the bare bone, non-medical services & medical equipment not covered by insurance… I’m waiting…
Cost -benefit analysis? Will the insurance companies buy-in? This problem goes back to when we started decreasing length of stay. Did not have as much of this problem then.
The care team continues meeting even after the patient is discharged? Is someone contacting the patient after discharge? How are these continued services reimbursed within the health care system?
I love it! I’m just wondering how it’s plausible to have the team continue to meet after discharge. It seems that eventually, the team would have far too many people to meet about as more and more patients come to the hospital and would be unable to keep up. But it would probably go a long way to reduce the incidence of repospitalization for the patient if it can be done.
ROI?out of pocket costs?
Who pays for what
Where in the EMR/patient portal does the list of goals reside so ALL of the team can see it? Is Frank paid by Medicare to care for the couple or for John? How does this couple decide when to contact Dr. Endocrinology for blood sugar issues? Do they know to contact both Dr. Nephrology AND Dr. Arthritis when John is given an NSAID?
If John needs more therapy, how does the team in the Minimally Disruptive Medicine care model “work together to make sure the plan of care that is developed reduces the amount of work the couple must do and increases their capacity to do it.”
I am intrigued by the concepts and the vision.