by Rebecca Perez, MSN RN CCM

"The most expensive and challenging populations found in the current health care system will remain underserved until there is a unified effort- rather than small incremental steps- to improve care for the nation's high needs patients."

-National Academy of Medicine

Care provided to individuals with complex health needs is often the most expensive, inefficient, and poorly coordinated across medical, behavioral, and social providers (Humowiecki M, 2018). To promote health and wellness, a comprehensive approach to prevention is required. The Whole Person Care model is one such approach. Whole Person Care (WPC) goes beyond biopsychosocial care to focus more on the relationship between patient and provider, not on the illness, condition, or disease (Thomas H., 2018). WPC improves prevention efforts by addressing the factors that adversely affect an individual's ability to be healthy. This translates to focusing on 'health' and not 'sickness.' WPC is the next generation of population health management but will require additional efforts (Swift, 2020). Strong organizational leadership and local stakeholder partnerships are needed to locate and provide services as are necessary for the most at risk and vulnerable (Swift, 2020). Mental health, social services, and wellness activities need to be aligned with medical care. To create a whole person framework, the characteristics of the targeted population need to be determined: what social determinants are present, income status, social supports, who utilizes and who does not utilize health services, and all require analysis to determine what care management efforts and interventions will be most beneficial.

Individuals with multimorbid conditions pose a challenge in the coordination of care. Care from multiple providers is standard, and coordination of this care from various sites often falls to the primary care provider (PCP). With shrinking numbers of PCPs and the growing number of individuals with multimorbid conditions, PCPs struggle to manage (Humowiecki M, 2018). More practices are incorporating case management to assist with care coordination. Still, for those practices too small to hire case management staff, payer case managers can help with these activities. This is a smart investment as multidisciplinary primary care practices have been proven to contribute more to care coordination than solo practices (Kaufman, 2017).

WPC does not exclude any disease, condition, or circumstance. When executing a WPC model, one primary care provider addresses all needs that challenge an individual. The integration of medical and behavioral health is of itself a significant barrier. Health care professionals must be open to managing all the needs of a patient. Patients prefer the ability to receive most care and services in one location by trusted professionals. That doesn't mean specialists are no longer needed or accessed; instead, these are ancillary services coordinated by the PCP. At present, health care professionals remain challenged by a lack of complete integration of data, agendas, and health goals (Stumm, 2019). Most organizations agree that the problems facing individuals with complexity are that care is not sufficiently person-centered. Social determinants of health are not adequately addressed, data is scattered over multiple systems, and the current payment systems still reward volume over outcomes (Kaufman, 2017).

Case managers learn to engage and sustain trusted patient relationships as the primary contact managing all of their conditions, improve communication, advance assessment skills by learning to have a conversation instead of an interrogation. They understand the importance of removing bias and judgment, accept who the patient is: a unique individual with a unique story. Every individual with diabetes cannot be treated identically.

"I diagnosed abdominal pain when the real problem was hunger; I mislabeled

the hopelessness of long-term unemployment as depression and the poverty that

causes patients to miss pills or appointments as noncompliance. My medical training

had not prepared me for this ambush of social circumstance. Real-life obstacles had

an enormous impact on my patients' lives, but because I had neither the skills nor the

resources for treating them, I ignored the social context of disease altogether."

-Laura Gottlieb, MD

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