Cory B. Sevin, RN, MSN, NP, is a director with the Institute for Healthcare Improvement, and a nurse practitioner with a clinical specialty in Adolescent, Preventative and Community Health. She is also lead faculty for the
Better Health and Lower Costs for Complex Needs Collaborative.
This summer I will help IHI launch the Better Health and Lower Costs for Patients with Complex Needs Collaborative focused on how to improve care and decrease costs for patients with complex needs – the top tier of individuals who account for the highest health care costs. I love that a person-centered approach leads to solutions that decrease costs. It takes me back to when I was a new and naive nurse-practitioner.
I was putting my nurse practitioner skills to good use in teen clinic one evening when the unexpected happened. Little did I know the surprises in store and the journey I was about to embark on. My next patient had a minor complaint – teens often do, as a way to check you out to see if they can trust you with the “real stuff.” Taking her vital signs, I was surprised to find she had a very high blood pressure. Three more readings confirmed the initial reading. She needed further follow-up, and soon. I learned that she lived with her two sisters, mother, and grandmother just up the street from the clinic. Frances [not her real name] was adamant that her mother could not come down to the clinic and they had no phone. I made arrangements for a home visit the next morning.
Our teen program was in a very poor community; having done many home visits in the area, I knew I might encounter just about anything. I did not expect what I walked into. The apartment was sparsely furnished but clean. There was a mattress on the floor; lying on the mattress was an old woman, all joints severely contracted, the sun streaming through the windows on her face. In a chair was a very large woman reading a bible – Frances’s mother. Frances introduced me to her mother, who acknowledged me but said nothing.
Frances’ mother had not been out of the house for seven years. The girls did all the shopping and family business outside of the house. The woman on the mattress was their grandmother, who had had a stroke a number of years before. It took me hours that day to build enough of a connection with Frances’ mother to gain agreement and arrangements for Frances and her mother to go to the hospital. It was a BIG DEAL.
That day was the beginning of a seven-year relationship with this family. What at first appeared to be an extremely dysfunctional situation was actually a family struggling to support each other in life. Over time I saw that there was a deep love among them all. The grandmother was flawlessly cared for – never a pressure ulcer or any sign of neglect. The daughters were supported and loved, and family life was characterized by warmth and fun. Yes, there were also problems and crisis along the way, but when seen in the context of the strengths, the family was willing to engage and issues improved. Frances’s blood pressure was treated to normal, the other two girls received support for their development, and, over time, the mother went more regularly out of the house.
In my seven years in this community, I learned a stance of non-judgment, a desire to connect with individuals on their own terms and turf and learn who they are; building on their strengths towards their goals was a recipe for “helping.” Although I was the “helper,” my life was enriched beyond measure as my eyes and heart were opened to the strengths, resourcefulness, and deep desires of people struggling through many challenges towards a better life.
This kind of relationship building, although effective, is tiring for one person, and in relation to the immense need I saw every day, did not seem like enough. I turned my eyes towards health care programs – surely, health care systems could be designed to better meet these needs. This vision drove my career over the next years and into quality improvement, but achieving this aim has proved elusive.
If you are in health care, it is likely you too have experienced relationships that have opened your eyes and heart and have felt like a gift. How could we do our work day after day without having such moments of connection – whether at the bedside of a very ill patient or in an office visit? These moments and connections carry us through the years, reminding us of our purpose, of our own humanity. They help us through the days that feel harsh and brutal, when we have to dig deep to tap the empathy we know we want to bring to our work. They are the real gifts to us from our careers in health care.
Through the work of the IHI Triple Aim and a workgroup focused on improving care of these “high-risk, high-cost” individuals, I see progress towards my dream. It turns out that connecting with individuals who are struggling, whose needs are complex and multi-layered, and who cost the health care system a lot of money, seems to be a key component of how to decrease costs. “Patient-centeredness” – the meaningful engagement of individual and families in what matters to them – helps the bottom line. We do know about methods health care organizations can use to learn about their “high-risk, high-cost” populations and design systems to meet their needs. The knowledge and skills I gained years ago with Frances and others, and that thousands of other individual clinicians have gained, can be harvested and used to design systems of care that improve the health of the individuals and decrease costs.