A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal,...

Area of Science:

• Healthcare Management
• Chronic Disease Management
• Health Services Research

Background:

• Individuals with complex chronic diseases account for a disproportionate amount of healthcare costs.
• These patients often present with co-occurring physical health conditions, behavioral health issues, and social determinants of health challenges.
• The multifaceted nature of their needs defies simple, isolated solutions.

Purpose of the Study:

• To present a novel two-phase framework designed to enhance health outcomes for patients with complex lives.
• To detail the operational components of this framework and share practical insights.
• To offer a structured approach for healthcare systems managing high-need populations.

Main Methods:

• Phase 1 involves case managers building trusting relationships with patients to collaboratively identify health goals and needs.
• This foundational phase requires significant time investment, patient acceptance, and sustained commitment.
• Phase 2 focuses on co-creating a wellness pathway, addressing prioritized issues, and adapting health systems.

Main Results:

• The described framework facilitates a patient-centered approach to complex care.
• Emphasis on relationship-building and trust is crucial for effective intervention.
• The model supports integrated care addressing physical, behavioral, and social needs.

Conclusions:

• A structured, relationship-based, two-phase framework can improve outcomes for patients with complex chronic diseases.
• Healthcare systems must adapt to support this patient-centered, holistic care model.
• Sustained case management and patient engagement are key to navigating complex health and social needs.