POPULATION HEALTH MANAGEMENT Volume 17, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2013.0040
A Person-Focused Model of Care for the Twenty-First Century: A System-of-Systems Perspective Robert A. Greene, MD, Edwin Dasso, MD, Sam Ho, MD, Ash M. Genaidy, PhD (Epidemiol), PhD (Eng)
Abstract
The US health care system is challenged to provide high-quality care and is burdened with unsustainable expenditures, making it difficult for health care participants (patients, payers, providers, caregivers) to create value. This communication presents the theoretical foundation for a person-focused model of care that addresses a number of these challenges. The model integrates aspects of prior models of chronic care with new empiric findings and complex adaptive system (CAS) theory. The model emphasizes the relationship among all health care stakeholders. The health care delivery process is examined in terms of the role of each stakeholder and the value each adds to and receives from the process. The authors present pilot results illustrating the implications of CAS theory in regard to multi-morbidity, disease management programs, multi-morbid households, and person- and household-focused care. The model incorporates the physical, mental, and social dimensions of health, and operationalizes an individual patient’s health as a CAS, identifying CASs for each of the other stakeholders as well. Health care can then be conceptualized as a system-of-systems with a person’s health as its output. Deploying the model need not require major infrastructure investments or changes. It can be implemented by repurposing, aligning, and better integrating currently available interventions. The authors believe that the model creates not only survival value (health) but also purposeful value. The model offers a unifying focus for all participants in the health care delivery process, thereby constructing a health care system that is structurally person-focused and meaningful for all participants. (Population Health Management 2014;17:166–171)
Introduction
T
he US health care system has yet to fully achieve the 6 aims for the twenty-first century health care system set forth by the Institute of Medicine (IOM) in 2001.1 Based on standard reports, the United States ranks number 1 in health care spending and 37th in overall health system performance.2 Furthermore, a recent report still finds scant evidence that the United States gets better value for its higher health care spending relative to other Organisation for Economic Co-operation and Development countries.3 Patients with chronic diseases drive the majority of health care costs. Chronic diseases, particularly those with multiple coexisting chronic conditions (multi-morbidity, or MM), are no longer the domain of the elderly population, but also the domain of the younger, working population.4 MM adds complexity to health care because of the interactions of diseases for a given patient and the special needs of multi-
morbid patients that cut across their diseases.5 Inadequate attention to those 2 factors impairs the quality of care. Therefore, MM drives the agenda for both the quality and cost of care for the US health care system.4–11 Based on their findings from a US population of fully insured working individuals and their household members, Greene and coworkers4 suggested that the classic Chronic Care Model of Wagner and others12–15 be broadened and generalized to account for the role of each stakeholder (patient, caregiver, provider, and payer) and the value each adds to and receives from the health care delivery process. In essence, the Wagner model implicitly assumes that the provider team is fully responsible for the treatment process of chronic care. Furthermore, although it calls for the involvement of an informed and motivated patient, it does not explicitly recognize the support that is needed in return for each stakeholder, and the relationships among them, that create person-focused care. In this context, the term person-focused
UnitedHealthCare, Minnetonka, Minnesota.
166
PERSON-FOCUSED MODEL OF CARE
care is in line with that of Starfield,16 with an emphasis on the whole person. For clarity and consistency with common usage, the authors of the present communication use ‘‘patient’’ at times instead of ‘‘person,’’ understanding that the intent remains ‘‘person-focused’’ care. Models of care and gaps in the current state of the art
There are 2 general classes of care models aimed at enhancing the quality and affordability of medical care and particularly chronic care. Although the first class is centered on either the Chronic Care Model developed by Wagner or a variation of it, the second class advocates the use of complex care models. The Chronic Care Model suggests that collaborative patient-provider interactions will result in improved outcomes, and the focus of care remains with the personal physician supported by an integrated and perhaps expanded practice team.12 In particular, the model predicts that improvement in its 6 interrelated components (ie, selfmanagement support, clinical information system, delivery system redesign, decision support, health care organization, community resources) can produce changes in which informed, motivated patients interact with prepared, proactive practice teams.14–15 Bodenheimer et al17 and Wagner et al18 indicated that there is mounting evidence for improving outcomes via the use of the Chronic Care Model and its components. Furthermore, the Chronic Care Model has been used in a variety of physical and mental medical conditions including diabetes and depression and as a template for improving prevention and health behaviors.19–21 Although the Chronic Care Model has shown promising results, it has not yielded the level of performance needed to address the significant cost burden of chronic conditions, particularly among multi-morbid patients.4,22 This may be attributed in part to it consisting primarily as an open system with feed-forward loops acting in a mostly top-down approach (ie, from providers to patients). Instead, feedback loops must be implemented in order to optimize personfocused outcomes; for example, through plan-do-check-act cycles. The relationships among stakeholders, and between stakeholders and the person’s health, then form multiple closed-loop improvement systems. Furthermore, the Wagner Chronic Care Model does not account for key stakeholders such as the payer. Equally important, the different types of relationships among the different stakeholders are not explicitly stated, included, and detailed. The second class of models of care attempts to address some of the aforementioned issues through complexity theory. In a series of articles by Sturmberg and colleagues, an attempt termed complex adaptive chronic care has been proposed as a bottom-up approach, via the patient’s experiences, to advance the Chronic Care Model.23–26 This class of models intends to surpass current notions of disease management as an end point by building on the concept of chronicity, encompassing the patient’s journey of simple and complex phases through long-term asymptomatic disease to bodily dysfunction and illness, and including families and communities. In this respect, they advocate the use of complex adaptive systems (CASs) defined as systems that are characterized by interconnected agents that learn, adapt, self-organize, and coevolve through the influence of the agents and their environments on one another. Yet Sturm-
167
berg and colleagues did not develop quantitative methods through which they could operationalize and extend their concepts. Sturmberg’s model is a qualitative attempt to augment Wagner’s Chronic Care Model from the bottom up (from patient to provider) by bringing to light the complex interactions embedded in a person-focused care. Others also have discussed the need for use of complex systems in integrated care.27 The architecture of the aforementioned models of care does not fully account for the role of different health care stakeholders and their respective dynamic and varied relationships. Accounting for those roles and relationships is paramount to achieving person-focused care and a sustainable health care system, as advocated by the authors and by others in the published literature.16,28 Communication aim
This communication aims to lay the theoretical foundation for a general health care model with the goal of improving each person’s health as the common ground and unifying focus for all health care participants. The challenges facing the US health care system should be approached in the context of higher complexity than elsewhere in the world because of the diversity of public and private funding and the free market organization of providers. Thus, there is a need for an integrated framework that unites the social actors in US health care despite its varied structures and conditions. The health care delivery framework presented herein is predicated on 2 axioms: Axiom 1—Ensuring optimum conditions for each agent will result in improved patient outcomes at an affordable cost; Axiom 2—Ensuring optimum conditions for each agent will result in a sustainable environment for each agent. These axioms are adapted from the compatibility principles described elsewhere.29 The first axiom suggests that harmonious relationships among all participants in the health care delivery process are preconditions for achieving quality of care at an affordable cost. The second axiom maintains that the harmonious relationships among health care participants will result in satisfying the needs and wants of all participants in terms of connecting their survival needs to a higher purpose for each stakeholder. Examples are, among others, improved health promotion for the patient, including higher social and behavioral function; financial stability and meaningful work for providers; financial stability and social responsibility for payers; and decreased stress for caregivers in the setting of the improved health of their loved ones. Model Foundations
The foundation of the model hinges on broadening the umbrella of health as a resource for everyday living to include: (a) not only physical health but also mental and social health, and (b) not only ‘‘ill’’ health but also ‘‘positive’’ health. Patients’ health then can be understood as a CAS consisting of its mental, social, and physical aspects. The smallest unit of health care forms a tetrahedron of participants and acts as input to the patient’s health CAS (Figure 1). Additionally, patients interact with, influence, and are influenced by their caregivers, their social milieu, and the health care system as a whole. Each health care participant
168
GREENE ET AL.
FIG. 1. Person-focused care model (left) with complex adaptive systems shown (right). The 5 complex adaptive systems (CASs) are: (a) patient’s health (mental-social-physical) with relationships to patient, payer, caregiver, and clinicians; (b) person (ie, patient) with relationships to other entities; (c) caregiver with relationships to other entities; (d) clinician with relationships to other entities; and (e) the payer with relationships to other entities. The System of Systems consists of the 5 collaborative and interacting CASs. M, mental health; S, social health; P, physical health. Figure ª 2013 UnitedHealth Group. and his or her relationships thus form CASs as well. Therefore, health care consists of multiple interactive CASs and becomes a System of Systems (SoS) for each individual person, with his or her health status at its center and as its output. The idea of health as a resource is not new. In the midtwentieth century, the World Health Organization (WHO) defined health as a ‘‘resource’’ for everyday living.30 Furthermore, each person’s health in the proposed model is treated as multidimensional health status (with mental, social, and physical elements) (Figure 1a); this is also in line with the WHO’s later definition of health.31 Additionally, each of the 3 elements of health comprises both negative and positive aspects. For example, illness is the negative aspect of physical health; positive health is not just a lack of disease, which is a ‘‘pathogenic’’ orientation. Patients may have disease, but care seen only through the lens of disease is inherently not person-focused.16,28 The authors propose taking into account Antonovsky’s salutogenic perspective,32 which reflects health promotion rather than only disease treatment and prevention. In a pathogenic orientation, one understands results in terms of disease outcomes. The salutogenic perspective allows the capture of additional important functional outcomes and values. In this regard, value is maximized by capturing both ‘‘outcome’’ and ‘‘functional’’ values. Functional value33 for the patient takes 2 forms: those that allow the satisfaction of survival needs (eg, working toward restoring and improving ‘‘physical health’’ resources for the patient) and those that allow patients to increase their societal contribution (eg, working toward improving ‘‘mental and social functioning and resources’’ for the patient). A system of health care includes the roles of various stakeholders such as health care providers (eg, clinicians, facilities), caregivers (including social support systems as a general case) and payers (eg, employers, health benefit plans, government agencies). Consequently, the model
highlights the CAS for each stakeholder and their relationships as depicted in Figure 1b. The model explicitly recognizes 3 classes of interactions; that is, (a) interactions among the mental, social, and physical dimensions of a patient’s health (the intrapersonal CAS), (b) the interactions among all stakeholders with each other, including the patient (the interagent CASs), and (c) the interaction between each stakeholder and the patient’s health, which is the output of the model. There are, in turn, elements of 5 sets of CASs: each entity’s relationships to the other, and each to the patient’s health. The model offers a framework with which to consider a diverse set of intra-/inter-hierarchical interventions from the scientific and medical literature (and how to add to them as needed) and unites them in cohesive and integrated ways, while leveraging the principles of CASs. The 3 elements of health—physical, mental, and social— have long been recognized as mutually interacting, as exemplified in Romano and Engel’s Biopsychosocial Model.34 Therefore, it makes sense to model a patient’s health as a set of CASs, thus augmenting the recent notion of health as ‘‘the ability to adapt and to self-manage.’’35 Furthermore, the inputs to the multiple dimensions of health are the resources brought by each stakeholder, as processed within the patient and among the stakeholders to produce the patient’s health status. Accordingly there are direct relationships to health status (eg, clinician to patient health) and indirect relationships (eg, patient relationship to payers and then payer relationships to clinicians and caregivers) that must be taken into account. In this regard, each entity both monitors the patient’s health status and takes steps to improve it, thus forming natural plan-do-check-act cycles.36 Furthermore, each interaction between stakeholders can be improved by addressing defects and seizing opportunities through standard quality improvement methods. Structuring health care as a system of CASs (ie, SoS) with the patient’s multidimensional health resource at its center yields the value of health care activities for the patient,
PERSON-FOCUSED MODEL OF CARE
accomplishing, as Porter37 puts it, the key goal that ‘‘matters for patients and unites the interests of all parties.’’ By collecting and respecting the patient’s wishes, the system would then in fact deliver person-focused care. The authors believe the proposed model of care can be operationalized in both bottom-up (ie, person out) and top-down (eg, provider to person) ways so as to address the IOM’s 6 aims while continuously optimizing health outcomes for the patient in an inherently and truly person-focused fashion. Clinical Example of CAS and SoS Implications
The authors have conducted a pilot that illustrates several of the implications described in the foregoing theoretical discussion. The pilot participants actively signed up for health plan actions that were offered to them as part of their benefits plan and the health plan’s care operations. The reported findings were from the primary activity of the plan’s health care operations as defined by the Health Insurance Portability and Accountability Act (45 CFF 164.501) and were not from a research activity; therefore, institutional review board oversight was not required. The patient population represented a group with established MM including at least chronic pain and depression. Furthermore, the population was characterized by high total and individual health care costs. The study group consisted of 382 UnitedHealthcare (UHC) fully insured, commercial patients who were contacted (ie, whether ultimately enrolled or not, as ‘‘intent to treat’’) and the control group, which included 1912 patients who were not contacted. Of the patients contacted, 146 were enrolled as the participants in the study group. In this project, UHC constructed an SoS for each patient with health as its output and consisting of 5 CASs: (1) the patient’s mental, social, and physical health (intrapersonal CAS); (2) the patient and the patient’s interpersonal relationships to other entities (interpersonal CAS); (3) the caregiver and the caregiver’s relationships to other entities (with caregiver defined as another UHC insured adult living in the same location as the patient); (4) the treating physician with relationships to other entities; and (5) the payer (eg, UHC behavioral health coach) with relationships to other entities. After the authors identified potential study patients, a health coach enrolled them in the project and constructed a care plan including behavioral health coaching. The payer connected patients to primary care physicians and behavioral health professionals as needed. The infrastructure facilitated collaborative efforts among all stakeholders through a customized set of integrated interventions for each patient, shared with all participants. The patient’s health was monitored as the output of this SoS. The pilot project confirmed a number of important potential implications of the CAS and SOS approach:
The intrapersonal CAS suggests that working on behavioral health would improve patients’ medical outcomes. The authors demonstrated a statistically significant decrease in outpatient services, inpatient admissions, and opioid analgesic use in these chronic pain patients. The average savings in health care spending for the study group relative to the control group participant was over 10% per member per year in the full intent-to-treat group, across inpatient, outpatient, physician, and pharmacy services.
169
The model’s second implication is a social effect (through the patient-caregiver CAS) proposing that caregivers also will start with higher costs and levels of psychosocial stress. Baseline health care utilization for caregivers in this pilot was substantially high, 7 times the cost of the average member filing claims. In addition, the caregivers had an even higher risk for depression than the index patients. The model suggests that one should look for an indirect SoS effect on the caregivers. Data showed that for the first few months after the patients’ enrollment in the program, the caregivers’ medical service utilization rose, and then consistently trended downward, suggesting that improvement in the patients’ health status allowed the caregivers to attend to built up demand for addressing their own health issues. Even more importantly, it appears that as the index patients improved, their caregivers had decreased utilization as well. If that in fact reflects improved caregiver health, the project may have created a virtuous circle through the CAS between patients and their caregivers. Because the patient and caregiver form CASs, there will then be a positive feedback loop that helps the index patient even further as the caregiver improves as well. In this way, the CAS and SoS concepts enabled the capture of much greater value than previous approaches, and suggest additional actions such as implementing a caregiver support system in the future. In the authors’ experience, although disease and case management programs usually are applied to individual diseases, the patients they enroll have MM, such as those discussed in the pilot information presented. Therefore, these programs have inherent limitations. The authors believe that the proposed model’s structure provides broader
FIG. 2. The framework collapsed to show how the role of and value-added to and received by each stakeholder in the health care delivery process creates survival value (SV) and purposeful value (PV), along the lines of Maslow’s hierarchy of needs. Blue arrows indicate the balance of lower and higher needs within the entity or stakeholder in the system. Green arrows correspond to the relationships shown in the model and indicate the balance among the needs between the different entities or stakeholders in the system.
170
capabilities with many important implications that integrate across diseases, specialties, sites of service, and aspects of health itself in a holistic way. The model allows the thorough exploration of the varied opportunities for optimizing the care of patients with MM beyond the classic view of index diseases. It addresses the cross-disease needs of multimorbid patients such as care coordination, self-management skills, and caregiver/family support.5 The concept of SoS precludes a single-specialty approach, a site of service-based approach such as hospital-based utilization, or a solely dyadic physician/provider-oriented approach. Instituting health coaching and caregiver support are 2 examples of resources that cut across diseases and sites of service and help implement a SoS. Lastly, and most important, an SoS integrates the behavioral and social components of health, while traditional disease management programs tend to focus on the medical aspects. Further research is needed to advance the utility of SoS in improving clinical and health economic outcomes within the health care delivery process. The results of the pilot are consistent with the findings reported by Greene et al4 concerning the prevalence of multimorbid households (ie, 2 or more members possessing chronic conditions in the same household) in the insured population with at least 50.1% of the population and costing 51.1% of the total expenditures for chronic care. All caregivers also suffered from chronic conditions. These findings amplify the role of and value added to/by each stakeholder in the health care delivery process—in particular, the patient(s) and caregiver(s) and their interactions with other participants in the process. In this regard, the high prevalence of multimorbid households highlights the need to elevate personfocused care to household-focused care. Therefore, one must provide information and closely monitor its flow in order to truly advance the cooperative efforts of agents in the SoS toward both person- and household-focused care. In addition, a successful model of care should reflect an underlying premise that each stakeholder’s activities must produce their own survival value (SV) as well as purposeful value (PV), while creating value concordance among stakeholders. This is in line with the theoretical underpinnings of Maslow’s hierarchy of needs38 with regard to the balance and respect between the lower and higher needs of and among individuals. Figure 2 shows how the model framework in fact produces SV and PV for each participant. For example, patients contribute to their own physical health (ie, SV) while increasing their social functioning (ie, PV). Similarly, providers of care increase their SV through efficient interactions, while increasing their PV as reflected by improving their patient population health in concordance with the highest principles of the medical profession. By unifying each health care participant’s focus around the value they add to a person’s health and the value received in return, the framework creates value concordance. PV brings meaningfulness to activities. The authors believe that creating SV and PV for each health care participant is a key to sustainability of the health care system as a whole.33 Conclusions
The care of persons with MM is a challenging task for all stakeholders because of unsustainable costs and the com-
GREENE ET AL.
plexity of care programs required to tackle the multiple chronic diseases and the associated non-chronic conditions. The approach described herein represents a sociotechnical approach39 to address many of these challenges. The social element is required in every step to maintain the human touch among all stakeholders’ relationships in the SoS, which is a must for the approach to succeed. The technical element does not require extreme innovation but it must be balanced and synchronized with the social element in every step. The proposed model can be deployed in a practical fashion by repurposing current health care resources and/or making new investments as necessary. Physicians, pharmacists, and behavioral health counselors could be utilized more effectively than current practice would suggest. Case and disease managers could be retrained and redirected to address issues related to MM instead of specific conditions. Health coaches and shared decision making may represent new investments to enhance the knowledge and change the behavior of patients and caregivers regarding clinicians’ instructions. Better coordination of existing resources will be essential. Ultimately, a well-coordinated, multidisciplinary approach may achieve better health outcomes and demonstrate lower medical costs based on a more rational deployment of clinical and lay resources. As depicted in the clinical example of CASs forming an SoS, the notion of SoS is a key concept that has the potential to transform the US health care system into truly personand household-focused care that meets the US IOM’s 6 aims. As such, the common goal of all stakeholders is to continuously improve patient health in all its aspects. Future research should be directed to further theoretical development and validation of the framework presented in this communication as well as further practical implications. Interconnecting each individual patient’s SoS model across multiple patients, caregivers, payers, and providers will create a ‘‘System of SoS’’ that could place the US health care system on a sustainable track of efficiency and effectiveness that will accelerate building healthier lives. Author Disclosure Statement
Drs. Greene, Dasso, Ho, and Genaidy declared no conflicts of interest with respect to the research, authorship, and/ or publication of this article. The authors received no financial support for this article. References
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001. 2. IBM Institute for Business Value. Healthcare 2015: winwin or lose-lose? A portrait and a path to successful transformation. Somers, NY: IBM Global Services, 2006. 3. Anderson GF, Frogner BK. Health spending in OECD countries: obtaining value per dollar. Health Aff (Millwood) 2008;27(6):1718–1727. 4. Greene RG, Dasso E, Ho S, Frank J, Scandrett G, Genaidy A. Patterns and expenditures of multi-morbidity in an insured working population in the United States: insights for sustainable healthcare system and building healthier lives. Popul Health Manag Epub ahead of print August 22, 2013.
PERSON-FOCUSED MODEL OF CARE
5. Parekh AK, Goodman RA, Gordon C, Koh HK; HHS Interagency Workgroup on Multiple Chronic Conditions. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep 2011;126:460–471. 6. Gulley SP, Rasch EK, Chan L. The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep 2011;126:495–507. 7. Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the ‘‘bridges to health’’ model. Milbank Q 2007;85:185–208. 8. Boyd CM, Fortin M. Future of multimorbidity research: how should understanding of multimorbidity inform health system design? Public Health Rev 2010;32:451–474. 9. Dawes M. Co-morbidity: we need a guideline for each patient not a guideline for each disease. Fam Pract 2010;27(1):1–2. 10. Campbell-Scherer D. Multimorbidity: a challenge for evidencebased medicine. Evid Based Med 2010;15:165–166. 11. Glynn L. Multimorbidity: another key issue for cardiovascular medicine. Lancet 2009;374:1421–1422. 12. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2–4. 13. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288(14):1775–1779. 14. World Health Organization. Innovative care for chronic conditions: building blocks for action. Geneva, Switzerland: World Health Organization, 2002. 15. Wagner EH, Austin BT, von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74(4):511–544. 16. Starfield B. Is patient-centered care the same as personfocused care? Permanente J 2011;15(2):63–69. 17. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness, the chronic care model part 2. JAMA 2002;288(15):1909–1914. 18. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001;20(6):64–78. 19. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79(4):579–612. 20. Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q 2007;85(1):69–91. 21. McEvoy P, Barnes P. Using the chronic care model to tackle depression among older adults who have long-term physical conditions. J Psychiatr Ment Health Nurs 2007;14:233–238. 22. Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O’Connor PJ. Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med 2006;4(4):310–316. 23. Sturmberg JP, O’Halloran DM, Martin CM. People at the centre of complex adaptive health systems reform. Med J Aust 2010;193(8):474–478.
171
24. Sturmberg JP, Martin CM. The dynamics of health care reform—learning from complex adaptive systems theoretical perspective. Nonlinear Dynamics Psychol Life Sci 2010;14(4):525–540. 25. Sturmberg J. How to teach holistic care—meeting the challenge of complexity in clinical practice. Edu Health (Abingdon) 2005;18(2):236–245. 26. Martin C, Sturmberg J. Complex adaptive chronic care. J Eval Clin Pract 2008;15:571–577. 27. Edgren L. The meaning of integrated care: a systems approach. Int J Integrat Care 2008; 8(23):1–6. 28. Coiera E, Hovenga EJS. Building a sustainable health system. Yearb Med Inform 2007:11–18. 29. Genaidy A, Karwowski W, A-Rehim A. The work compatibility improvement framework: preliminary findings of a case study for defining and measuring the human-at-work system. Ergonomics 2007;50(11):1771–1808. 30. World Health Organization. Preamble to the constitution of the World Health Organization as adopted by the International Health Conference. New York, June 19–22, 1946, and entered into force on April 7, 1948. Available at: < http://www.who.int/about/definition/en/print.html > . Accessed September 11, 2013. 31. World Health Organization. Ottawa Charter for Health promotion. First International Conference on Health Promotion. Ottawa, November 17–21 1986. Available at: < http://www.who.int/hpr2/archive/docs/ottawa.html > . Accessed September 11, 2013. 32. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11(1):11–18. 33. Parrish BD. Designing the sustainable enterprise. Futures 2007;39:846–860. 34. Frankel R, Quill T, McDaniel S. The biopsychosocial approach: past, present, future. Rochester, NY: University of Rochester Press, 2003. 35. Huber M, Knottnerus JA, Green L, et al. How should we define health? Br Med J 2011;343:4163–6165. 36. Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. 37. Porter ME. What is value in health care? N Engl J Med 2010;363:2477–2481. 38. Maslow A. A theory of human motivation. Psychol Rev 1943;50(4):370–396. 39. Cherns A. The principles of sociotechnical design. Human Relations 1976;29(8):783–792.
Address correspondence to: Ash M. Genaidy, PhD (Epidemiol), PhD (Eng) Clinical Services, UnitedHealthcare 9050 Centre Point OH-035 West Chester, OH, 45069 E-mail: [email protected]
A Person-Focused Model of Care for the Twenty-First Century: A System-of-Systems Perspective Robert A. Greene, MD, Edwin Dasso, MD, Sam Ho, MD, Ash M. Genaidy, PhD (Epidemiol), PhD (Eng)
Abstract
The US health care system is challenged to provide high-quality care and is burdened with unsustainable expenditures, making it difficult for health care participants (patients, payers, providers, caregivers) to create value. This communication presents the theoretical foundation for a person-focused model of care that addresses a number of these challenges. The model integrates aspects of prior models of chronic care with new empiric findings and complex adaptive system (CAS) theory. The model emphasizes the relationship among all health care stakeholders. The health care delivery process is examined in terms of the role of each stakeholder and the value each adds to and receives from the process. The authors present pilot results illustrating the implications of CAS theory in regard to multi-morbidity, disease management programs, multi-morbid households, and person- and household-focused care. The model incorporates the physical, mental, and social dimensions of health, and operationalizes an individual patient’s health as a CAS, identifying CASs for each of the other stakeholders as well. Health care can then be conceptualized as a system-of-systems with a person’s health as its output. Deploying the model need not require major infrastructure investments or changes. It can be implemented by repurposing, aligning, and better integrating currently available interventions. The authors believe that the model creates not only survival value (health) but also purposeful value. The model offers a unifying focus for all participants in the health care delivery process, thereby constructing a health care system that is structurally person-focused and meaningful for all participants. (Population Health Management 2014;17:166–171)
Introduction
T
he US health care system has yet to fully achieve the 6 aims for the twenty-first century health care system set forth by the Institute of Medicine (IOM) in 2001.1 Based on standard reports, the United States ranks number 1 in health care spending and 37th in overall health system performance.2 Furthermore, a recent report still finds scant evidence that the United States gets better value for its higher health care spending relative to other Organisation for Economic Co-operation and Development countries.3 Patients with chronic diseases drive the majority of health care costs. Chronic diseases, particularly those with multiple coexisting chronic conditions (multi-morbidity, or MM), are no longer the domain of the elderly population, but also the domain of the younger, working population.4 MM adds complexity to health care because of the interactions of diseases for a given patient and the special needs of multi-
morbid patients that cut across their diseases.5 Inadequate attention to those 2 factors impairs the quality of care. Therefore, MM drives the agenda for both the quality and cost of care for the US health care system.4–11 Based on their findings from a US population of fully insured working individuals and their household members, Greene and coworkers4 suggested that the classic Chronic Care Model of Wagner and others12–15 be broadened and generalized to account for the role of each stakeholder (patient, caregiver, provider, and payer) and the value each adds to and receives from the health care delivery process. In essence, the Wagner model implicitly assumes that the provider team is fully responsible for the treatment process of chronic care. Furthermore, although it calls for the involvement of an informed and motivated patient, it does not explicitly recognize the support that is needed in return for each stakeholder, and the relationships among them, that create person-focused care. In this context, the term person-focused
UnitedHealthCare, Minnetonka, Minnesota.
166
PERSON-FOCUSED MODEL OF CARE
care is in line with that of Starfield,16 with an emphasis on the whole person. For clarity and consistency with common usage, the authors of the present communication use ‘‘patient’’ at times instead of ‘‘person,’’ understanding that the intent remains ‘‘person-focused’’ care. Models of care and gaps in the current state of the art
There are 2 general classes of care models aimed at enhancing the quality and affordability of medical care and particularly chronic care. Although the first class is centered on either the Chronic Care Model developed by Wagner or a variation of it, the second class advocates the use of complex care models. The Chronic Care Model suggests that collaborative patient-provider interactions will result in improved outcomes, and the focus of care remains with the personal physician supported by an integrated and perhaps expanded practice team.12 In particular, the model predicts that improvement in its 6 interrelated components (ie, selfmanagement support, clinical information system, delivery system redesign, decision support, health care organization, community resources) can produce changes in which informed, motivated patients interact with prepared, proactive practice teams.14–15 Bodenheimer et al17 and Wagner et al18 indicated that there is mounting evidence for improving outcomes via the use of the Chronic Care Model and its components. Furthermore, the Chronic Care Model has been used in a variety of physical and mental medical conditions including diabetes and depression and as a template for improving prevention and health behaviors.19–21 Although the Chronic Care Model has shown promising results, it has not yielded the level of performance needed to address the significant cost burden of chronic conditions, particularly among multi-morbid patients.4,22 This may be attributed in part to it consisting primarily as an open system with feed-forward loops acting in a mostly top-down approach (ie, from providers to patients). Instead, feedback loops must be implemented in order to optimize personfocused outcomes; for example, through plan-do-check-act cycles. The relationships among stakeholders, and between stakeholders and the person’s health, then form multiple closed-loop improvement systems. Furthermore, the Wagner Chronic Care Model does not account for key stakeholders such as the payer. Equally important, the different types of relationships among the different stakeholders are not explicitly stated, included, and detailed. The second class of models of care attempts to address some of the aforementioned issues through complexity theory. In a series of articles by Sturmberg and colleagues, an attempt termed complex adaptive chronic care has been proposed as a bottom-up approach, via the patient’s experiences, to advance the Chronic Care Model.23–26 This class of models intends to surpass current notions of disease management as an end point by building on the concept of chronicity, encompassing the patient’s journey of simple and complex phases through long-term asymptomatic disease to bodily dysfunction and illness, and including families and communities. In this respect, they advocate the use of complex adaptive systems (CASs) defined as systems that are characterized by interconnected agents that learn, adapt, self-organize, and coevolve through the influence of the agents and their environments on one another. Yet Sturm-
167
berg and colleagues did not develop quantitative methods through which they could operationalize and extend their concepts. Sturmberg’s model is a qualitative attempt to augment Wagner’s Chronic Care Model from the bottom up (from patient to provider) by bringing to light the complex interactions embedded in a person-focused care. Others also have discussed the need for use of complex systems in integrated care.27 The architecture of the aforementioned models of care does not fully account for the role of different health care stakeholders and their respective dynamic and varied relationships. Accounting for those roles and relationships is paramount to achieving person-focused care and a sustainable health care system, as advocated by the authors and by others in the published literature.16,28 Communication aim
This communication aims to lay the theoretical foundation for a general health care model with the goal of improving each person’s health as the common ground and unifying focus for all health care participants. The challenges facing the US health care system should be approached in the context of higher complexity than elsewhere in the world because of the diversity of public and private funding and the free market organization of providers. Thus, there is a need for an integrated framework that unites the social actors in US health care despite its varied structures and conditions. The health care delivery framework presented herein is predicated on 2 axioms: Axiom 1—Ensuring optimum conditions for each agent will result in improved patient outcomes at an affordable cost; Axiom 2—Ensuring optimum conditions for each agent will result in a sustainable environment for each agent. These axioms are adapted from the compatibility principles described elsewhere.29 The first axiom suggests that harmonious relationships among all participants in the health care delivery process are preconditions for achieving quality of care at an affordable cost. The second axiom maintains that the harmonious relationships among health care participants will result in satisfying the needs and wants of all participants in terms of connecting their survival needs to a higher purpose for each stakeholder. Examples are, among others, improved health promotion for the patient, including higher social and behavioral function; financial stability and meaningful work for providers; financial stability and social responsibility for payers; and decreased stress for caregivers in the setting of the improved health of their loved ones. Model Foundations
The foundation of the model hinges on broadening the umbrella of health as a resource for everyday living to include: (a) not only physical health but also mental and social health, and (b) not only ‘‘ill’’ health but also ‘‘positive’’ health. Patients’ health then can be understood as a CAS consisting of its mental, social, and physical aspects. The smallest unit of health care forms a tetrahedron of participants and acts as input to the patient’s health CAS (Figure 1). Additionally, patients interact with, influence, and are influenced by their caregivers, their social milieu, and the health care system as a whole. Each health care participant
168
GREENE ET AL.
FIG. 1. Person-focused care model (left) with complex adaptive systems shown (right). The 5 complex adaptive systems (CASs) are: (a) patient’s health (mental-social-physical) with relationships to patient, payer, caregiver, and clinicians; (b) person (ie, patient) with relationships to other entities; (c) caregiver with relationships to other entities; (d) clinician with relationships to other entities; and (e) the payer with relationships to other entities. The System of Systems consists of the 5 collaborative and interacting CASs. M, mental health; S, social health; P, physical health. Figure ª 2013 UnitedHealth Group. and his or her relationships thus form CASs as well. Therefore, health care consists of multiple interactive CASs and becomes a System of Systems (SoS) for each individual person, with his or her health status at its center and as its output. The idea of health as a resource is not new. In the midtwentieth century, the World Health Organization (WHO) defined health as a ‘‘resource’’ for everyday living.30 Furthermore, each person’s health in the proposed model is treated as multidimensional health status (with mental, social, and physical elements) (Figure 1a); this is also in line with the WHO’s later definition of health.31 Additionally, each of the 3 elements of health comprises both negative and positive aspects. For example, illness is the negative aspect of physical health; positive health is not just a lack of disease, which is a ‘‘pathogenic’’ orientation. Patients may have disease, but care seen only through the lens of disease is inherently not person-focused.16,28 The authors propose taking into account Antonovsky’s salutogenic perspective,32 which reflects health promotion rather than only disease treatment and prevention. In a pathogenic orientation, one understands results in terms of disease outcomes. The salutogenic perspective allows the capture of additional important functional outcomes and values. In this regard, value is maximized by capturing both ‘‘outcome’’ and ‘‘functional’’ values. Functional value33 for the patient takes 2 forms: those that allow the satisfaction of survival needs (eg, working toward restoring and improving ‘‘physical health’’ resources for the patient) and those that allow patients to increase their societal contribution (eg, working toward improving ‘‘mental and social functioning and resources’’ for the patient). A system of health care includes the roles of various stakeholders such as health care providers (eg, clinicians, facilities), caregivers (including social support systems as a general case) and payers (eg, employers, health benefit plans, government agencies). Consequently, the model
highlights the CAS for each stakeholder and their relationships as depicted in Figure 1b. The model explicitly recognizes 3 classes of interactions; that is, (a) interactions among the mental, social, and physical dimensions of a patient’s health (the intrapersonal CAS), (b) the interactions among all stakeholders with each other, including the patient (the interagent CASs), and (c) the interaction between each stakeholder and the patient’s health, which is the output of the model. There are, in turn, elements of 5 sets of CASs: each entity’s relationships to the other, and each to the patient’s health. The model offers a framework with which to consider a diverse set of intra-/inter-hierarchical interventions from the scientific and medical literature (and how to add to them as needed) and unites them in cohesive and integrated ways, while leveraging the principles of CASs. The 3 elements of health—physical, mental, and social— have long been recognized as mutually interacting, as exemplified in Romano and Engel’s Biopsychosocial Model.34 Therefore, it makes sense to model a patient’s health as a set of CASs, thus augmenting the recent notion of health as ‘‘the ability to adapt and to self-manage.’’35 Furthermore, the inputs to the multiple dimensions of health are the resources brought by each stakeholder, as processed within the patient and among the stakeholders to produce the patient’s health status. Accordingly there are direct relationships to health status (eg, clinician to patient health) and indirect relationships (eg, patient relationship to payers and then payer relationships to clinicians and caregivers) that must be taken into account. In this regard, each entity both monitors the patient’s health status and takes steps to improve it, thus forming natural plan-do-check-act cycles.36 Furthermore, each interaction between stakeholders can be improved by addressing defects and seizing opportunities through standard quality improvement methods. Structuring health care as a system of CASs (ie, SoS) with the patient’s multidimensional health resource at its center yields the value of health care activities for the patient,
PERSON-FOCUSED MODEL OF CARE
accomplishing, as Porter37 puts it, the key goal that ‘‘matters for patients and unites the interests of all parties.’’ By collecting and respecting the patient’s wishes, the system would then in fact deliver person-focused care. The authors believe the proposed model of care can be operationalized in both bottom-up (ie, person out) and top-down (eg, provider to person) ways so as to address the IOM’s 6 aims while continuously optimizing health outcomes for the patient in an inherently and truly person-focused fashion. Clinical Example of CAS and SoS Implications
The authors have conducted a pilot that illustrates several of the implications described in the foregoing theoretical discussion. The pilot participants actively signed up for health plan actions that were offered to them as part of their benefits plan and the health plan’s care operations. The reported findings were from the primary activity of the plan’s health care operations as defined by the Health Insurance Portability and Accountability Act (45 CFF 164.501) and were not from a research activity; therefore, institutional review board oversight was not required. The patient population represented a group with established MM including at least chronic pain and depression. Furthermore, the population was characterized by high total and individual health care costs. The study group consisted of 382 UnitedHealthcare (UHC) fully insured, commercial patients who were contacted (ie, whether ultimately enrolled or not, as ‘‘intent to treat’’) and the control group, which included 1912 patients who were not contacted. Of the patients contacted, 146 were enrolled as the participants in the study group. In this project, UHC constructed an SoS for each patient with health as its output and consisting of 5 CASs: (1) the patient’s mental, social, and physical health (intrapersonal CAS); (2) the patient and the patient’s interpersonal relationships to other entities (interpersonal CAS); (3) the caregiver and the caregiver’s relationships to other entities (with caregiver defined as another UHC insured adult living in the same location as the patient); (4) the treating physician with relationships to other entities; and (5) the payer (eg, UHC behavioral health coach) with relationships to other entities. After the authors identified potential study patients, a health coach enrolled them in the project and constructed a care plan including behavioral health coaching. The payer connected patients to primary care physicians and behavioral health professionals as needed. The infrastructure facilitated collaborative efforts among all stakeholders through a customized set of integrated interventions for each patient, shared with all participants. The patient’s health was monitored as the output of this SoS. The pilot project confirmed a number of important potential implications of the CAS and SOS approach:
The intrapersonal CAS suggests that working on behavioral health would improve patients’ medical outcomes. The authors demonstrated a statistically significant decrease in outpatient services, inpatient admissions, and opioid analgesic use in these chronic pain patients. The average savings in health care spending for the study group relative to the control group participant was over 10% per member per year in the full intent-to-treat group, across inpatient, outpatient, physician, and pharmacy services.
169
The model’s second implication is a social effect (through the patient-caregiver CAS) proposing that caregivers also will start with higher costs and levels of psychosocial stress. Baseline health care utilization for caregivers in this pilot was substantially high, 7 times the cost of the average member filing claims. In addition, the caregivers had an even higher risk for depression than the index patients. The model suggests that one should look for an indirect SoS effect on the caregivers. Data showed that for the first few months after the patients’ enrollment in the program, the caregivers’ medical service utilization rose, and then consistently trended downward, suggesting that improvement in the patients’ health status allowed the caregivers to attend to built up demand for addressing their own health issues. Even more importantly, it appears that as the index patients improved, their caregivers had decreased utilization as well. If that in fact reflects improved caregiver health, the project may have created a virtuous circle through the CAS between patients and their caregivers. Because the patient and caregiver form CASs, there will then be a positive feedback loop that helps the index patient even further as the caregiver improves as well. In this way, the CAS and SoS concepts enabled the capture of much greater value than previous approaches, and suggest additional actions such as implementing a caregiver support system in the future. In the authors’ experience, although disease and case management programs usually are applied to individual diseases, the patients they enroll have MM, such as those discussed in the pilot information presented. Therefore, these programs have inherent limitations. The authors believe that the proposed model’s structure provides broader
FIG. 2. The framework collapsed to show how the role of and value-added to and received by each stakeholder in the health care delivery process creates survival value (SV) and purposeful value (PV), along the lines of Maslow’s hierarchy of needs. Blue arrows indicate the balance of lower and higher needs within the entity or stakeholder in the system. Green arrows correspond to the relationships shown in the model and indicate the balance among the needs between the different entities or stakeholders in the system.
170
capabilities with many important implications that integrate across diseases, specialties, sites of service, and aspects of health itself in a holistic way. The model allows the thorough exploration of the varied opportunities for optimizing the care of patients with MM beyond the classic view of index diseases. It addresses the cross-disease needs of multimorbid patients such as care coordination, self-management skills, and caregiver/family support.5 The concept of SoS precludes a single-specialty approach, a site of service-based approach such as hospital-based utilization, or a solely dyadic physician/provider-oriented approach. Instituting health coaching and caregiver support are 2 examples of resources that cut across diseases and sites of service and help implement a SoS. Lastly, and most important, an SoS integrates the behavioral and social components of health, while traditional disease management programs tend to focus on the medical aspects. Further research is needed to advance the utility of SoS in improving clinical and health economic outcomes within the health care delivery process. The results of the pilot are consistent with the findings reported by Greene et al4 concerning the prevalence of multimorbid households (ie, 2 or more members possessing chronic conditions in the same household) in the insured population with at least 50.1% of the population and costing 51.1% of the total expenditures for chronic care. All caregivers also suffered from chronic conditions. These findings amplify the role of and value added to/by each stakeholder in the health care delivery process—in particular, the patient(s) and caregiver(s) and their interactions with other participants in the process. In this regard, the high prevalence of multimorbid households highlights the need to elevate personfocused care to household-focused care. Therefore, one must provide information and closely monitor its flow in order to truly advance the cooperative efforts of agents in the SoS toward both person- and household-focused care. In addition, a successful model of care should reflect an underlying premise that each stakeholder’s activities must produce their own survival value (SV) as well as purposeful value (PV), while creating value concordance among stakeholders. This is in line with the theoretical underpinnings of Maslow’s hierarchy of needs38 with regard to the balance and respect between the lower and higher needs of and among individuals. Figure 2 shows how the model framework in fact produces SV and PV for each participant. For example, patients contribute to their own physical health (ie, SV) while increasing their social functioning (ie, PV). Similarly, providers of care increase their SV through efficient interactions, while increasing their PV as reflected by improving their patient population health in concordance with the highest principles of the medical profession. By unifying each health care participant’s focus around the value they add to a person’s health and the value received in return, the framework creates value concordance. PV brings meaningfulness to activities. The authors believe that creating SV and PV for each health care participant is a key to sustainability of the health care system as a whole.33 Conclusions
The care of persons with MM is a challenging task for all stakeholders because of unsustainable costs and the com-
GREENE ET AL.
plexity of care programs required to tackle the multiple chronic diseases and the associated non-chronic conditions. The approach described herein represents a sociotechnical approach39 to address many of these challenges. The social element is required in every step to maintain the human touch among all stakeholders’ relationships in the SoS, which is a must for the approach to succeed. The technical element does not require extreme innovation but it must be balanced and synchronized with the social element in every step. The proposed model can be deployed in a practical fashion by repurposing current health care resources and/or making new investments as necessary. Physicians, pharmacists, and behavioral health counselors could be utilized more effectively than current practice would suggest. Case and disease managers could be retrained and redirected to address issues related to MM instead of specific conditions. Health coaches and shared decision making may represent new investments to enhance the knowledge and change the behavior of patients and caregivers regarding clinicians’ instructions. Better coordination of existing resources will be essential. Ultimately, a well-coordinated, multidisciplinary approach may achieve better health outcomes and demonstrate lower medical costs based on a more rational deployment of clinical and lay resources. As depicted in the clinical example of CASs forming an SoS, the notion of SoS is a key concept that has the potential to transform the US health care system into truly personand household-focused care that meets the US IOM’s 6 aims. As such, the common goal of all stakeholders is to continuously improve patient health in all its aspects. Future research should be directed to further theoretical development and validation of the framework presented in this communication as well as further practical implications. Interconnecting each individual patient’s SoS model across multiple patients, caregivers, payers, and providers will create a ‘‘System of SoS’’ that could place the US health care system on a sustainable track of efficiency and effectiveness that will accelerate building healthier lives. Author Disclosure Statement
Drs. Greene, Dasso, Ho, and Genaidy declared no conflicts of interest with respect to the research, authorship, and/ or publication of this article. The authors received no financial support for this article. References
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001. 2. IBM Institute for Business Value. Healthcare 2015: winwin or lose-lose? A portrait and a path to successful transformation. Somers, NY: IBM Global Services, 2006. 3. Anderson GF, Frogner BK. Health spending in OECD countries: obtaining value per dollar. Health Aff (Millwood) 2008;27(6):1718–1727. 4. Greene RG, Dasso E, Ho S, Frank J, Scandrett G, Genaidy A. Patterns and expenditures of multi-morbidity in an insured working population in the United States: insights for sustainable healthcare system and building healthier lives. Popul Health Manag Epub ahead of print August 22, 2013.
PERSON-FOCUSED MODEL OF CARE
5. Parekh AK, Goodman RA, Gordon C, Koh HK; HHS Interagency Workgroup on Multiple Chronic Conditions. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep 2011;126:460–471. 6. Gulley SP, Rasch EK, Chan L. The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep 2011;126:495–507. 7. Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the ‘‘bridges to health’’ model. Milbank Q 2007;85:185–208. 8. Boyd CM, Fortin M. Future of multimorbidity research: how should understanding of multimorbidity inform health system design? Public Health Rev 2010;32:451–474. 9. Dawes M. Co-morbidity: we need a guideline for each patient not a guideline for each disease. Fam Pract 2010;27(1):1–2. 10. Campbell-Scherer D. Multimorbidity: a challenge for evidencebased medicine. Evid Based Med 2010;15:165–166. 11. Glynn L. Multimorbidity: another key issue for cardiovascular medicine. Lancet 2009;374:1421–1422. 12. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2–4. 13. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288(14):1775–1779. 14. World Health Organization. Innovative care for chronic conditions: building blocks for action. Geneva, Switzerland: World Health Organization, 2002. 15. Wagner EH, Austin BT, von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74(4):511–544. 16. Starfield B. Is patient-centered care the same as personfocused care? Permanente J 2011;15(2):63–69. 17. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness, the chronic care model part 2. JAMA 2002;288(15):1909–1914. 18. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001;20(6):64–78. 19. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79(4):579–612. 20. Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtree BF. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q 2007;85(1):69–91. 21. McEvoy P, Barnes P. Using the chronic care model to tackle depression among older adults who have long-term physical conditions. J Psychiatr Ment Health Nurs 2007;14:233–238. 22. Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O’Connor PJ. Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med 2006;4(4):310–316. 23. Sturmberg JP, O’Halloran DM, Martin CM. People at the centre of complex adaptive health systems reform. Med J Aust 2010;193(8):474–478.
171
24. Sturmberg JP, Martin CM. The dynamics of health care reform—learning from complex adaptive systems theoretical perspective. Nonlinear Dynamics Psychol Life Sci 2010;14(4):525–540. 25. Sturmberg J. How to teach holistic care—meeting the challenge of complexity in clinical practice. Edu Health (Abingdon) 2005;18(2):236–245. 26. Martin C, Sturmberg J. Complex adaptive chronic care. J Eval Clin Pract 2008;15:571–577. 27. Edgren L. The meaning of integrated care: a systems approach. Int J Integrat Care 2008; 8(23):1–6. 28. Coiera E, Hovenga EJS. Building a sustainable health system. Yearb Med Inform 2007:11–18. 29. Genaidy A, Karwowski W, A-Rehim A. The work compatibility improvement framework: preliminary findings of a case study for defining and measuring the human-at-work system. Ergonomics 2007;50(11):1771–1808. 30. World Health Organization. Preamble to the constitution of the World Health Organization as adopted by the International Health Conference. New York, June 19–22, 1946, and entered into force on April 7, 1948. Available at: < http://www.who.int/about/definition/en/print.html > . Accessed September 11, 2013. 31. World Health Organization. Ottawa Charter for Health promotion. First International Conference on Health Promotion. Ottawa, November 17–21 1986. Available at: < http://www.who.int/hpr2/archive/docs/ottawa.html > . Accessed September 11, 2013. 32. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11(1):11–18. 33. Parrish BD. Designing the sustainable enterprise. Futures 2007;39:846–860. 34. Frankel R, Quill T, McDaniel S. The biopsychosocial approach: past, present, future. Rochester, NY: University of Rochester Press, 2003. 35. Huber M, Knottnerus JA, Green L, et al. How should we define health? Br Med J 2011;343:4163–6165. 36. Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. 37. Porter ME. What is value in health care? N Engl J Med 2010;363:2477–2481. 38. Maslow A. A theory of human motivation. Psychol Rev 1943;50(4):370–396. 39. Cherns A. The principles of sociotechnical design. Human Relations 1976;29(8):783–792.
Address correspondence to: Ash M. Genaidy, PhD (Epidemiol), PhD (Eng) Clinical Services, UnitedHealthcare 9050 Centre Point OH-035 West Chester, OH, 45069 E-mail: [email protected]
