Meeting the Challenge of High-Risk, Complex Patients in the VA System
Donna Zulman, MD, MS (assistant professor, general medical disciplines), is intrigued by the challenge of caring for patients with multiple medical issues, often exacerbated by mental illness or social stressors. “Developing care plans for these patients requires a solid grasp of individuals’ unique circumstances and priorities,” says Zulman. “However, physicians rarely have access to a comprehensive picture of the factors influencing their patients’ health.”
Zulman’s goal is to identify interventions and approaches that support individualized care for complex patients. Her three years as a Robert Wood Johnson clinical scholar at the University of Michigan and her work in the Veterans Administration system for the past 11 years have given her the skills to design, implement, and evaluate programs that do just that.
As a Stanford undergraduate, Zulman majored in Human Biology, taking courses on health and behavior, psychology, and health policy. This diverse coursework fostered her ambition to develop holistic models of health care that address both medical needs and social and behavioral factors that influence health and access to care. Early on, she gravitated toward the VA. “The VA offered a unique opportunity to care for complicated patients in a system that has a strong social mission backed by comprehensive services.”
The VA offers extensive resources. In addition to medical, mental health, and social work services, veterans have access to peer support, rehabilitation services, recreation therapy, and programs for caregivers. Many are assisted in finding employment and housing. Zulman says, “We work in a team-based fashion, so we can focus on patients’ medical concerns but when social issues come up we can refer patients to a whole host of services.”
Still, “some patients’ needs are so intense they can overwhelm the system, especially in the time allotted for most clinic visits.” Several years ago, Zulman found that five percent of patients account for nearly 50 percent of VA spending—a statistic also observed in the U.S. population. “The vast majority of high-cost patients have multiple different chronic conditions, and approximately half have a mental health diagnosis, driving a need for care coordination.”
Such patients became the focus of a Palo Alto VA pilot program that Zulman is now evaluating. The program, called ImPACT (Intensive Management Patient Aligned Care Team), aims to improve high-risk veterans’ health and wellbeing, and—if possible—keep them out of the hospital and emergency room. The ImPACT team includes a nurse practitioner, social worker, recreation therapist, and physician. The team has a small panel of patients and offers intensive case management and chronic disease support. As Zulman describes, “This structure allows the team to spend time getting to know their patients, visiting them in their homes if necessary, and working with their other providers to improve care coordination and discharge planning.” When patients have an advanced illness, the team works hard to understand and meet their goals for end-of-life care.
Zulman believes that when it comes to supporting clinically complex patients, the promises of technology are far from achieved. “Better tools are urgently needed to improve and individualize care,” she says. A Viewpoint commentary on this topic written by Zulman and coauthors Nigam Shah, MBBS, PhD (associate professor, biomedical informatics research) and Abraham Verghese, MD (professor of medicine and vice chair for the theory and practice of medicine) appeared in JAMA in September 2016.
What pushes Donna Zulman to work with such challenging patients? “It’s the opportunity to work on a complicated problem that spans multiple disciplines.” Zulman is seeing a shift from a disease-oriented paradigm to an approach that offers patients personalized care across all their needs. “It’s an exciting time to be doing this type of work, and there’s a lot of energy and support to do it.”