Collaborating for care: When joining forces helps patients

Patients with chronic illnesses must navigate a complex regimen of multiple physicians and medications. Coordination of the medical team supports patients by improving care and avoiding hospitalizations.

By Amy Snow Landa, AMNews correspondent. April 21, 2003.

When Ed Wagner, MD, conjures up the image of a typical patient with chronic conditions, he thinks of "Ms. G.," a 69-year-old living with diabetes, high blood pressure and heart disease. Moderately obese, her diabetes is not well controlled, and she is confused by diet and exercise recommendations. She sees her primary care physician when she is having trouble, but the visits are brief and don't leave time to address her concerns about managing all her ailments.

Over time, Ms. G.'s heart disease progresses to congestive heart failure. One night she becomes so short of breath that she calls 911, is taken to the emergency department, and admitted to the hospital. After two days, she leaves with new diet plans and six prescriptions. Tests indicate impaired kidney function and she is referred to a nephrologist. She is also urged to make appointments with the cardiologist who treated her in the hospital and with her primary care internist.

Although feeling much better, Ms. G. is even more confused -- about her new medications, her diet, and the need for more doctor visits. She calls her internist's office, but he isn't aware of her hospitalization or new medications. She fills the prescriptions but has difficulty with compliance. Over the next few weeks, she begins to have trouble breathing. Ultimately, she returns to the ED, where she is found to have relatively severe congestive heart failure.

This composite case history, based on real patients, illustrates how people with chronic illnesses can often end up being hospitalized with complications that could have been avoided. Even though Ms. G. is receiving care from competent physicians, she is not doing as well as she could be, said Dr. Wagner, a general internist/epidemiologist and director of Group Health Cooperative's MacColl Institute for Healthcare Innovation in Seattle. He also heads up the Improving Chronic Illness Care program, a 5-year-old initiative funded by the Robert Wood Johnson Foundation.