Flipping the Clinic: On Brainstorming Innovation by Patient Type

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)

It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone’s health needs at the same time?

In other words, are we likely to come up with good ideas when we’re striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple “mundane” chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including “self-healthcare” such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren’t thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we’re a healthcare provider, we’re thinking of the needs of those patients that we spend the most time with, or are most interested in.

Common Types of Patients

The peril of attempting a taxonomy or classification exercise is that one easily ends up with too much complexity and detail.

Still, I find it helpful to roughly classify patients (by which I mean people when they are in the role of receiving a service from the professional healthcare system).

So my favorite part of Flip the Clinic was when I sat with two other women, and we came up with a very rough taxonomy of patients based on matching life stage and health needs with primary care services.

I liked thinking about this so much that I’ve expanded on it below. Note however that this list isn’t meant to encompass everyone in the US. Rather, it’s meant to list certain groups that are large by population size or by impact on the healthcare system. These are the ones for whom it might make sense to focus on, when problem-solving.

Common types of patients

  • Children:
    • Healthy children with none-few lifestyle risk factors
      • e.g. normal BMI, stable homes
    • Healthy children with few-many lifestyle risk factors
    • Children with a mild-moderate chronic condition
      • e.g. asthma
    • Children with a moderate-severe chronic condition
      • e.g. auto-immune disease, cancer
  • Young and middle-aged adults 
    • Healthy adults with none-few lifestyle risk factors
    • Healthy adults with few-many lifestyle risk factors
      • lifestyle risk factors include personal behaviors as well as environmental and situational factors like caregiving and poverty
    • Adults with one to a few chronic conditions of mild intensity
      • These are conditions that can be fairly easily ignored by patients.
      • e.g. HTN, GERD, mild Type 2 DM
    • Adults with one to a few chronic conditions of moderate intensity
      • These are conditions that aren’t easily ignored by patients, and might even be very burdensome to them. These might also require a lot of assistance from health providers, but don’t cause frequent hospitalization in most patients
      • e.g. CHF, CAD, COPD, Type 1 DM, mod-sev Type 2 DM, auto-immune disease
    • Adults with many chronic conditions of mild-moderate intensity
      • These are the people who have lots of chronic problems but don’t get hospitalized very often
      • e.g. diabetes, HTN, mild COPD, afib, depression, knee pain all in the same person
    • Adults with one to a few chronic conditions of severe intensity
      • These are conditions that may cause patients to re-organize their whole life
      • e.g. cancer, severe auto-immune disease, advanced CHF
      • could further subdivide by whether they have a rare disease or not
  • Medicare seniors with no substantial chronic functional impairments. These are the seniors who are able to live in their homes, and can manage ADLs and most IADLs without the help of another person.
    • Healthy seniors with non-few lifestyle risk factors
    • Healthy seniors with few-many lifestyle risk factors
    • Seniors with one to a few chronic conditions of mild intensity
      • e.g. Type 2 diabetes not on hypoglycemic agent, HTN, mild arthritis
    • Seniors with one to a few chronic conditions of moderate intensity
      • e.g. atrial fibrillation, stage 2+ COPD, CHF
    • Seniors with many chronic conditions of mild-moderate intensity
    • Seniors with 1+ chronic conditions of severe intensity
      • These seniors usually also have several chronic conditions of mild-moderate intensity, which often fall off the radar when a senior is hospitalized.
    • Frail or vulnerable seniors (usually of advanced age) with minimal diagnosed chronic conditions
      • These seniors hardly go to the doctor. Many of them end up developing dementia or another chronic condition that isn’t diagnosed for a while. They may experience falls, depression, and other geriatric syndromes.
  • Medicare seniors with chronic functional impairments. These are the seniors who require regular help or supervision from other people, due to cognitive problems or physical limitations. Caregivers — paid or family — are chronically involved in their life care and health care.
Being a geriatrician, of course I find it hardest to decide how to create categories for the last group, because that’s where I’m most aware of the distinctions that seem significant.

If I were going to flip a primary care clinic for older adults with chronic impairments, would I organize my ideas based on

  • whether or not the patient had dementia (which affects just about everything)?
  • whether or not we are facing limited life expectancy?
  • whether the senior lives at home versus a residential facility versus a nursing home?
  • whether it’s someone who has been in and out of the hospital or ED a lot?
  • whether there are just a few versus 6+ chronic conditions for the patient and family to juggle?

I haven’t yet decided, but perhaps that will be in a future blog post.

 

Have you come across a patient classification scheme you like?

I am sure that insurers and big organizations like Kaiser have found a way to classify us as patients. But are there any classifications easily available to innovators and healthcare improvers?

So far my brief Google search has turned up a list of these three patient types that population health managers should know about, but not much else. (The types are high-risk, rising-risk, and low-risk, which I think isn’t enough to guide development of a good Flip.)

If you come across anything interesting related to this, I hope you’ll let me know.

Otherwise, stay tuned for the follow-up post, in which I share my list of seven things people want from their healthcare. We can then have fun brainstorming better ways to deliver these things to different types of patients.

Addendum April 2016: Here’s a Deloitte analysis in which they segment healthcare consumers.

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