Croakey has reported previously on the general support across the sector for the principle of health care homes and raised some stakeholder concerns about their implementation.
These views are echoed below by Ben Harris, General Manager, Policy Information and Programs at Arthritis and Osteoporosis Victoria, who also argues for the potential benefits of health care homes and emphasises the need for consumer-centred outcomes for determining their success. .
In relation to bone, muscle and joint conditions, Harris argues that if the goal of ‘reducing pain’ is given a greater focus when defining outcome measures than ‘improving function’, it could inadvertently increase the already high rate of opioid prescription in Australia and not reflect the interests and priorities of consumers.
This example, no doubt one among many across the spectrum of chronic disease, highlights the importance of robust consumer consultation and ongoing stakeholder input into the development and implementation of the health care homes policy, if it is to deliver on its potential to improve outcomes for people with chronic and complex conditions.
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Ben Harris writes:
A Federal Election campaign is not the place for nuanced and complicated health reform proposals. We can expect the next ten weeks to be dominated by slogans, dubious claims, and fatuous predictions about the doom to befall the health system if the other team gets in.
That’s why the government released a proposal to trial health care homes to address the care needs of people with multiple chronic conditions well ahead of the election. The health sector has generally offered qualified support for the health care homes trial the government is proposing.
Health care homes are a recommendation of the Primary Health Care Advisory Group report. This report’s key recommendations pretty much read the same as they would have a generation ago. Indeed many of the problems identified in the report are repeated from the landmark General Practice Reform Strategy released in 1992.
Problems with the current system
We know the problems – poor information flows, different funding streams and incentives, and focusing on outputs rather than outcomes. The proposed solutions in this report are similar to previous efforts – for example, health care homes seem to be an update on the coordinated care trials of the 1990s.
The language and tone has shifted a bit, with a greater emphasis on shared electronic health records, multidisciplinary care teams and patient empowerment. It’s all moving in the right direction, and I am generally pleased that the government is having another go at this approach. But I am not yet excited.
You get what you measure. Consumer-friendly functional indicators to measure the success of health care homes is the key to shifting the goalposts to a reward system based on outcomes.
For a few thousand years now, we have been working with a health system based on preventing death and eradicating disease. The gains in health over that period have been astonishing, no more so than in the last century.
A new phase for health
We are now in a new phase for health and wellbeing. Gains in health care are more marginal, and thus we need to be working harder to ensure that the reach of health care improves. The report’s focus on those with multiple chronic diseases is absolutely right.
Where the report falters is in an intrinsic belief that the health system as it is remains the right frame of reference to improve the health and wellbeing of people living with multiple chronic conditions. That assumption is wrong. The objective with chronic health conditions is not to cure the sick; the objective is to improve quality of life.
Improving quality of life involves a more functional approach to health care than simply eradicating disease. Extending life should not come at the expense of living that life well. How to measure an improved quality of life should be entirely up to the patient.
There are over 6 million Australians with muscle, bone and joint conditions, many of whom live with disability and pain. As health care homes are going to initially concentrate on people with multiple chronic conditions, it’s more than likely that most of the trial participants will have a muscle, bone and joint condition as one of their chronic conditions to be managed. Thus improved pain management will need to be a key outcome measured in the trials.
Balancing outcomes
But what is the outcome that should be measured, and how do we reward the health care home for improving health? There is a balance needed between reducing pain and maintaining or enhancing function. Using too much medication can reduce pain significantly, but at a cost of reducing mental acuity, restricting physical function and/or risk of addiction.
Australian doctors prescribe way too many painkillers. Australia’s population increased by 29% between 1991-2010, yet the opioid base supply increased by 228% (Nicholas 2013). There is strong evidence that mindfulness and movement are very effective for pain management, yet such helpful techniques are underutilised.
There is also emerging evidence from an upcoming study funded by Arthritis and Osteoporosis Victoria that patients don’t like the effects of painkillers. These findings are consistent with data from our 1800 263 265 muscle, bone and joint help line, where about a third of callers have concerns about the pain medication they have been prescribed.
We are very concerned that a measured target of ‘reduced pain’ for enrolled patients is likely to see health care homes increase the use of prescription painkillers, rather than reduce dependence on opiods in favour of more effective interventions.
Consumer-friendly indicators
If health care homes are told to use purely clinical indicators, the result will be a clinical response. To make the most of health care homes, indicators must be functional, and determined by the patient in consultation with their family and their care team.
Asking people what they want to achieve and measuring that, rather than clinical indicators, will increase compliance and improve quality of life. For example, instead of a goal of reducing BMI, a goal might be to put shoes and socks on without assistance. Instead of a generic goal of reducing pain, a goal may be to be able to sit through a movie comfortably.
Activity and pain management goals based on what patients want to do is more likely to result in the goals of increasing activity, reducing weight, and improving diet. Functional indicators set by patients may also have a profound effect on participants’ quality of life.
Health care homes have the potential to help patients improve their health and well being. The gains for patients, their families and friends and the community as a whole will be maximised if we can use health professionals’ skills to help meet personal goals.
Ben Harris is General Manager, Policy Information and Programs at Arthritis and Osteoporosis Victoria. For advice on muscle, bone and joint conditions, call our free Help Line on 1800 263 265.
