How Contessa Solves Healthcare Fragmentation

Even as a physician, navigating a recent medication change took me two weeks of frustrating back and forth phone calls and messages to my doctor, pharmacy and insurance company. My insurance payer had changed the approved brand of medication, the pharmacy had listed incompatible alternatives and my physician was not updated on any of this. In spite of my familiarity with healthcare and its systems, I had become a casualty of a phenomenon known as healthcare fragmentation. 

In the United States, the structure of the healthcare system and its many services, initiatives and programs often results in healthcare fragmentation. Although we don’t often talk about its impacts, healthcare fragmentation means that patients often receive their care from an excessive number of sources that are not coordinated or talking with each other in meaningful ways. 

Because these various sources of healthcare services typically operate as independent entities, even with the best of intentions patients often fall through the proverbial cracks. A patient could ultimately have several different specialists seeing them for the same problem with conflicting medication prescriptions or treatment recommendations. 

Contessa’s Comprehensive Care at Home model provides a unique opportunity to reduce this problem of healthcare fragmentation, and to improve outcomes for the patients we serve. With our end-to-end care coordination and multiple programs of care, we are able to weave together a patient journey through the healthcare system that unburdens them from the complexities of traditional care delivery. 

Healthcare fragmentation in traditional care models 

In the traditional model of healthcare delivery, patients with complex medical conditions are usually referred by their primary care physician (PCP) to highly specialized doctors. A patient with rheumatoid arthritis, for example, might tap into this resource for the high level of expertise that specialists can offer in treating that condition. 

Challenges with this arise when patients with multiple chronic, serious conditions must see multiple specialists for care. This scenario is especially true for older patients, with 70% of Medicare beneficiaries diagnosed with two or more chronic conditions.  

 In this highly fragmented system, where care is often not well-coordinated, we see several negative outcomes:  

• Polypharmacy- research shows that patients who are taking 5 or more medications are at increased risk for adverse drug reactions, falls, renal dysfunction, hospitalization, functional decline and even mortality

• Excess office visits- more than one specialist means multiple visits to multiple providers, sometimes for overlapping problems, with some visits arguably unnecessary

• Duplicate and excess testing- providers who are not communicating with each other may repeat testing that was already completed at another visit; adverse clinical outcomes from polypharmacy may drive symptoms that require more testing as well  

The impact on acutely ill patients 

These negative impacts are further exacerbated in acute illness. Patients who have decompensated or developed a new condition requiring acute inpatient-level care are then discharged into a situation where follow-up and care is a daunting task.  

They leave the hospital, oftentimes with a loved one who is just as confused sorting through the maze of instructions, prescriptions and follow-up visits they are saddled with on their way out of the hospital doors. 

This situation can be equated to doing a workout with a spotter: except, right at the point a patient is tired, exhausted, and struggling with four times the weight they would normally carry, the spotter walks away and tells them “good luck.”    

Understandably, we can then see why so many patients are lost to follow up or readmitted to the hospital. These problems have further impact on: 

• The cost of care- high costs are associated with readmissions, duplication of testing and medications, etc.

• Patient and provider relationships- the more fragmented the system, the less the patient’s PCP is involved in directing their care 

• The quality of care- patients are less able to advocate for their own goals of care and suffer lower quality of life 

• “Burnout”- this lack of stable connection with patients is a driving factor in clinicians losing enthusiasm for the profession and sometimes leaving 

Healthcare fragmentation and social determinants of health 

The problems posed by healthcare fragmentation are also happening against the backdrop of social determinants of health. Even before all the challenges that fragmentation introduces, we already know that patients’ outcomes are heavily dependent on their social environment, their social status, and their income.  

Healthcare fragmentation adds increased utilization, increased cost, and poor quality of care to the complex ways in which patients’ lives are set up. And it adversely affects people with higher levels of adverse social determinant factors.  

Consider the impact on people who may live in a neighborhood with less robust transportation infrastructure, less social support, and less food security: if they must choose between eating lunch and going for a CT scan or doctor visit, it’s easy to understand how one might outbid the other.  

These effects on our patient population exacerbate basic inequities in our healthcare system and our society that already exist. The less coordination of care, the worst that effect is on the most vulnerable in our society. 

How Contessa’s Comprehensive Care at Home model solves healthcare fragmentation 

Contessa’s structure plays a crucial role in solving healthcare fragmentation. Comprehensive Care at Home is woven into the patient’s home environment and focuses on coordinating care around a patient’s everyday needs and routine. This contrasts with trying to execute care in a foreign, disempowering environment for the patient, often without clear insight into what their needs will be after they leave.  

Comprehensive Care at Home is built to be a care model that brings together all the elements of care that a patient could need, from Recovery Care at Home for their hospital-level care, to Rehabilitation Care at Home for their skilled nursing needs at home, and to Palliative Care at Home to give them extra support for complex, chronic illness.  

We coordinate these elements across multiple specialists as needed, organize their follow-up, arrange transportation, and make sure that we follow up after doctor visits. We also work on improving patients’ health literacy, and actively search for issues with polypharmacy and gaps in care. 

In that sense, Contessa has designed fragmentation out of the model of care at home. This is driven in part by the structure of our joint venture partnerships, where shared risk means a vested interest in looking for the best outcomes at the end of the program, not just in enrolling patients. And we know that minimizing all the adverse effects of fragmented care improves those outcomes.  

A model driven by experience and data 

Contessa is able to successfully implement this strategy with the help of both experience and robust data science driven by our proprietary informatics platform. This gives us the ability to transition patients from an acute phase of care to a monitoring period where they are reconnected with their primary care doctor and primary specialists. It is also what allows us to expand the services we offer into further lines of care like Rehabilitation Care at Home and Palliative Care at Home.  

This expansive care in the home goes to the very heart of what we do. It is also of huge value to the health systems which might otherwise struggle with this type of care—because managing medical care in the home is not really what they do. A partnership with Contessa, then, holds significant value, as it increases the quality of care and care coordination, reduces cost, and improves patient and provider relationships by providing the “workout spotter” that gets them through health concerns and back to where they need to be. 

The long view of gaps in healthcare and how to eliminate them 

As healthcare continues to evolve, its success will be tied to how well gaps in coordinating and delivering care are addressed, as well as avoiding wasteful duplication and harm. Rising to that challenge effectively will require novel ways of approaching care delivery, such as reducing healthcare fragmentation.  

The average patient, aside from wanting to be healthy, wants to be comfortable, not just in mind and body but in location. The last thing they want to do, if they can help it, is to spend a lot of time in a foreign environment, where they have limited access to the people they love the most. 

By its very nature, Comprehensive Care at Home is on the leading edge of innovative care in the home. It is no surprise then, that it also organically addresses the problem of healthcare fragmentation. Looking to the future, the continued expansion of our service lines will further eliminate the challenges posed by fragmented care in the traditional system.