A Call for Complex Care Curricula: Geriatric Providers Should Not Only Heed but Lead the Call

Brooke E. Salzman, MD; Lauren R. Hersh, MD


J Am Geriatr Soc. 2021;69(2):333-335. 

It is well established that a small percentage (5%) of patients with complex health and social needs use a disproportionate share (50%) of medical care.[1] High healthcare utilization for this subset of patients comes with substantial costs for these individuals, the healthcare system, and society at large. Paradoxically, the high costs incurred by this heterogeneous group do not correlate with high-quality care, satisfaction with care, or improved patient outcomes. In fact, the opposite is true. These "superutilizers" often lack access to high-quality care, are dissatisfied with their care, and have poorer health status and worse health outcomes. The juxtaposition of high cost against poor outcomes is attributed to a healthcare delivery system that drives cyclical utilization and spiraling costs while failing to meet the health and social needs of complex patients.[2,3]

Much work has been performed to discover, describe, and address the major shortcomings of a U.S. healthcare delivery system that provides fragmented, expensive, and inequitable care while consistently failing to adequately address the health and social needs of our most vulnerable patients and communities.[2–7] Geriatricians and geriatric providers are at the forefront of this work and bring valuable insight and expertise to caring for patients with complex health and social needs. There are several successful clinical programs and models across the United States, many of which are derived from geriatric practice, that have emerged over the past two decades with promising impact on patient outcomes on individual and population-based levels.[2–7] Common elements of these models include utilizing datasets to identify high-risk patients, implementing time-intensive care management strategies to assist with care coordination and navigation, involving interprofessional care teams with diverse skill sets, and addressing underlying social determinants that are critical to shaping health.[2–7] The widespread adoption and dissemination of successful programs have been limited due to a number of barriers, including but not limited to a (1) fragmented healthcare system that fails to integrate and coordinate medical care, behavioral health, and social services; a (2) largely fee-for-service, volume-based payment system that fails to support the time-intensive, high-touch services that are necessary for high-needs patients; (3) an inadequate investment in clinical infrastructure in primary care and community-based programs; and (4) an outdated health professions education system that lags behind clinical innovation and generally continues to train students in outdated siloes, with organ or disease-based curricula and within the traditional boundaries of hospital walls.[2,3,8–10]

Academic Health Centers (AHCs) are uniquely positioned to lead innovation in the triad of healthcare delivery, health profession education, and clinical research and, as a result, hold tremendous potential for effecting positive change across these three pillars to address critical societal needs. Although some AHCs are stepping up to address the call to redesign care and realign incentives to address the health of populations, the overall shift to align educational pedagogies with these priorities has been slow.[8–10] This is in part because clinical practice innovations and successful models of care have not been widely adopted or disseminated and because these same models have rarely been translated into curricular frameworks within health profession training. Training the next generation of health professionals to effectively and compassionately care for our most vulnerable patients will require building skill sets that holistically support patients' medical, behavioral, and social needs within and outside traditional hospital walls. To achieve this goal, AHCs must assume leadership in supporting the development, assessment, and sustainability of successful models of care as training "laboratories" or innovative learning classrooms.[8–10] Furthermore, AHCs must recognize and resolve educational gaps that originate from dysfunctional healthcare systems, obsolete practices, and curricular omissions. We must provide training in healthcare delivery models that cultivate the competencies we seek to instill in our graduates, models that prioritize team-based collaboration; address both medical and social needs in a holistic, coordinated way; and provide care that is compassionate, inclusive, and equitable.[11–13]

The article by Hart et al, in this issue of JAGS, describes an important, innovative model of care for high-needs, high-cost patients, which provides teams of interprofessional students an experiential curriculum in complex care.[14] Hotspotting, based on the work of the Camden Coalition of Healthcare Providers and its founder, Jeffrey Brenner, MD, emphasizes building authentic healing relationships and empowering patients to manage their health, guided by four core principles of harm reduction, motivational interviewing, accompaniment, and trauma-informed care. Hotspotting involves the strategic use of data to direct time-intensive, hands-on interventions toward "high utilizers" with the aim of improving health and reducing high utilization and related costs.[15] Student hotspotting (SH) is the hotspotting model translated into an educational curriculum where students gain experience working in interprofessional teams and collaborating with patients demonstrating high-utilization patterns. As discussed by Hart et al, students develop critical competencies in interprofessional teamwork; identify and address root causes of high healthcare utilization; and develop skills crucial to building trusting, healing relationships.[14] Students learn through the patient's perspective the challenges of navigating the healthcare system, difficulties accessing behavioral and social services, and the impact of social determinants of health.

SH is a noteworthy example but certainly not the only experiential teaching model showing how students can add value to care when learning to transform our healthcare system to better serve complex patients. A growing body of research must focus on both the value of training in innovative models like SH and the value students can add as extenders of the healthcare team.[16,17] SH also serves as a useful teaching framework that takes place outside of hospital walls and engages patients in their homes and communities, with a focus on understanding social determinants of health. SH does more than teach students to screen for social factors that affect health but involves students in providing effective interventions supporting medical, economic, and social needs, as well as care coordination and engagement in health promotion. In this way, learners are trained to be problem solvers and part of the solution rather than merely recognizing the formidable problems of our healthcare system.[13,17,18]

Although the hotspotting model and the SH curriculum have limitations, proponents have responded to valid critiques through programmatic revision and improvement. For instance, the hotspotting program has historically excluded patients older than the age of 80 years, thereby disregarding the reality that older adults, particularly those with functional impairment, represent a substantial portion of the subset of "high-needs, high-cost" patients. The rationale for excluding older adults may have been based on misconceptions that the issues facing this group are less actionable than those of younger cohorts and that illness severity necessitates high utilization, even though multiple geriatric models dispel these notions. However, the SH hub at Thomas Jefferson University (TJU) made the decision to include patients aged 80 years and older after examining datasets, which identified many patients aged 80 years and older among its highest utilizers. Furthermore, the hub at TJU integrates key geriatric principles into the SH curriculum, such as the role of functional status and caregiver support, the importance of transitions in care and key components of a safe discharge plan, and the value of aligning care with patient goals and preferences. Including older adults in SH has enabled students to appreciate the unique and profound impact of social determinants of health specific to older populations.

The perspectives of geriatricians and geriatric providers, who initiated, shaped, and lead SH at TJU, have been essential to recognizing the synergy of the complex care movement and the field of geriatrics. It is well known among geriatric providers that we are complex care specialists and have extensive experience in creating nontraditional healthcare delivery models that better serve older, vulnerable populations. We demonstrate unique proficiency in managing multimorbidity, advanced illness, and biopsychosocial needs. We have long embraced and modeled interprofessional teamwork and specialize in individualized, person-centered, goal-aligned care. However, partnering with the complex care movement provides a vital opportunity to leverage our expertise; advocate for inclusion of older populations; and disseminate relevant geriatric models of care, best practices, and principles that are applicable to other vulnerable patients with complex needs. Geriatric providers have much to contribute to the complex care movement, and there is much at stake if we do not. Indeed, our engagement with complex care provides a crucial opportunity to extend geriatric education to more frontline healthcare providers.[19,20] In addition, the field of geriatrics can benefit from learning more about relevant approaches to other vulnerable patients with complex needs, including but not limited to those who are marginalized or disadvantaged and those with substance use disorders, mental health problems, and/or disabilities. Geriatricians and geriatric providers need to be leaders in complex care delivery and guide AHCs in the development of novel teaching models in complex care that improve healthcare systems. By aligning the foundations of geriatric innovation and the complex care movement, we create opportunities to highlight the credibility of geriatrics as a "meta-discipline," modernize health professions education, transform healthcare delivery, and support our vulnerable populations.[19]