We must move from the traditional confessional model of an isolated doctor and an isolated patient meeting privately in an exam room, toward a broader engagement across time and space between an effective primary healthcare team and the community they serve together.   Newer specialty fields in medicine like Family Medicine, Lifestyle Medicine, Palliative Medicine and Integrative Medicine provide that essential relationship-focused, team-based, complex care.

And the evidence is clear, family & primary care teams save lives, decrease disease burden, and limit the reliance on emergency and hospital care in study after study after study.   Health systems with a strong foundation in primary healthcare flourish and demonstrate far superior health outcomes for their people than those systems that over-rely on single-cause, single-cure approaches filled with sometimes unnecessary procedures, hospitalizations and ill-suited efforts toward illusive cures.

Episodic Complexity

Shifting from more theoretical constructs of complexity in primary healthcare setting towards a more pragmatic development of a user-friendly tool for hospital physicians to use to identify patients requiring complex care in the hospital setting, we learn from Bandini and his associates (Bandini, et al., 2018) about the importance of what they call episodic complexity in contrast to a patient status complexity (also known as multimorbidity). The traditional definition of a complex patient is one with two or more chronic conditions.

The authors point out that many people who have a complex health status may not require complex engagement with the health system. They give an example of a person with Diabetes, Hypertension, Coronary Artery Disease and moderate chronic kidney disease being admitted to the hospital with a simple case of community-acquired pneumonia. Although this person clearly meets the traditional definition of being a complex patient, his admission episode is quite simple, requiring a well-established protocol of antibiotics and oxygen, followed by a highly predictable improvement and discharge from the hospital back home. They contrast this with episodic complexity, which they define as having one or more of these characteristics or events during the current hospital episode:

1. Simultaneous instability of 3 or more organ systems
2. Episode requiring more time for thinking, handling relationships, and human/professional confrontations
3. No clear diagnostic/therapeutic paths indicated in Evidence-Based Medicine guidelines
4. Unplanned readmission for same cause within 1 month of D/C
5. Patient not responding to therapy
6. Episode requiring end-of-life decisions

Based on these 6 Episode Complexity factors, they found nearly a third of their patients had Episodic Complexity with a very high correlation with risk of death during hospitalization (25 X higher probability), and a clear connection to increasing the length-of-stay (by 4.5 days on average).   By far the most common episodic complexity factor was the increased need for time related to relationships during the care with patient, family, other professionals. One could see how a “disease-focused clinical pathway” that does not incorporate behavioral, relational, and conflictual factors might have very limited impact on important care outcomes like death and average length of hospital stay.