Working draft
An Orientation to Complexity Assessment
And draft of the “Minnesota Complexity Assessment Method”
For instructional and further development use
CJ Peek PhD, Macaran Baird MD, MS, and Eli Coleman PhD with faculty of the
University of Minnesota Department of Family Medicine and Community Health
Draft, 6/25/09
This orientation and resulting draft of the “Minnesota Complexity Assessment Method” is
adapted from materials and tools presented in Minneapolis in October 2005 by the authors cited below.
Huyse, FJ & Stiefel, F (Eds.) (2006). Integrated care for the
complex medically ill. The Medical Clinics of North America.
Elsevier, July 2006.
Lyons, J. (2006). Communimetrics: A
Measurement Theory for Service Delivery
Applications. In Huyse & Stiefel (2006).
Frits Huyse, C-L psychiatrist; Consultant, Integrated Care; Dept of
John Lyons, Mental Health Services and Policy
General Internal Medicine, University Medical Centre Groningen,
Program, Northwestern University, Chicago
The Netherlands.
For more information on this foundational work: www.INTERMEDfoundation.org
With permission and encouragement from Frits Huyse, an outpatient Minnesota Complexity
Assessment Method based on this work was created and modified through subsequent tests with
University of Minnesota Family Medicine faculty beginning in March 2006.
Contact: Macaran Baird, MD, MS; [email protected] or CJ Peek, PhD; [email protected]
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Contents of this orientation booklet:
Complexity and its signs
Complexity: What matters to whom
Assessing complexity complements assessing for diagnosis
Complexity measurement becomes communication about action, not just description
Dimensions for complexity assessment
Minnesota Complexity Assessment Record (4/23/09 draft)
Levels of application for complexity assessment
Making the observations—the complexity assessment interview; its place in medical education
Principles for selecting items for a complexity assessment tool; success factors for use
Complexity assessment Pocket Card (for “shorthand” complexity assessment)
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2
3
3
4
5
7
8
9
10
Complexity and its signs.
Every clinician has encountered “complex” patients and has reacted with “Oh my gosh”—but not
necessarily with a patterned vocabulary for exactly how the patient is complex and what to do about it.
Patient “complexity” is thought of as interference with standard care caused by severity or diagnostic
uncertainty, behavioral unreadiness, lack of social safety or participation, and disorganization of care
or difficult care system relationships. This requires a combination of usual care for a condition and
proactively designed, individualized care that addresses patient-specific sources of complexity—across
whatever diseases and conditions the patient may have.
Complexity affects clinical presentations, the choice and organization of care, and the clinical results
across diseases and conditions—interacting with disease-specific protocols for the care of individuals.
The purpose of complexity assessment is to name, understand, and act on these complicating factors in
the care of individuals and families.
The purpose of a complexity assessment tool is to provide a practical but systematic vocabulary and
action-based evaluation system that clinicians can use routinely use to improve the care of their
patients (and the lives of clinicians).
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Orientation to Complexity Assessment, 6/25/09
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A few signs of complexity:
• Number of doctors
• Number of medications
• Number of visits
• Number of services
• Number of failed services
• Number of diagnostic tests
• Number and length of admissions
•
•
•
•
•
•
Number of diagnoses & specialists
Number of unplanned clinic & ER/UC visits
Involvement in multiple helping systems
Difficult patient / clinician relationships
Lack of information on any of the above
Large gap between patient and clinician view on how
severe the symptoms are—or are expected to be
From “Crossing the Quality Chasm”, Institute of Medicine (2001):
“In increasingly complex patient populations with multiple health risks and needs requiring integrated care, our historic
fragmented health service delivery . . . leads to miscommunication, redundant, low quality, and dangerous care.”
Complexity: What matters to whom
Why complexity matters to clinicians
• Standard care may not work so well—“he’s back!”
• Strains your ability to do it all yourself
• Brings out commonplace limitations on teamwork
• Brings out “mind-body” splits in healthcare services
• Tempts you to label (or discount) the patient as “difficult”
“Most difficult patients started out merely as complex”
•
Tempts you to engage in “wishful thinking”—another test, scan, specialist, prescription, etc.
“When the situation calls for you to do something you can’t do, you do something you can do—if
you do anything at all”
Maxim from Ossorio (2006)
•
Wastes your time and emotional energy when not dealt with up front
“The right kind of time at the beginning of a case saves time over the life of the case”
Clinical mottos from Peek & Heinrich (1995)
Why complexity matters to payers and care systems
• A few % of the patients use a big % of the resources. Complex patients may be less than 10%
of a population, but may use a third or more of the resources (Kathol).
• Complex patients may complain and “doctor-shop” when the system is unable to meet them at
their true level of complexity
• Disease management (disease-specific protocols) go only so far with this population who may
have multiple interacting diseases and conditions
• Care management activities (and reimbursements) aimed at complexity (not just diseases) may
be a way to improve care and satisfaction—and control costs.
“Preventing the common and predictable case fractures and misunderstandings may be the most
important part of your job”
Why complexity matters to preceptors
• Residents and students are often confused or discouraged in the face of complex patients.
• They may view sources of complexity as outside their legitimate purview
• Preceptors and residents need more than “Oh my gosh!” when they see a complex patient
• They need a vocabulary for just how the patient is complex—and what to do about it—as a
normal part of their work
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Orientation to Complexity Assessment, 6/25/09
© 2009 University of Minnesota
Why complexity matters to patients themselves
• Patients are often confused by their own illnesses and life factors—have a hard time explaining
their own situation to family, friends, or even themselves
• Often confused by multiple stories from their own doctors
• May feel unwanted or like a failure that no one wants to see: “I’m difficult”
• May feel that no one is capable of doing justice to their situation
• Often wonder “why doesn’t the left hand know what the right hand is doing” in the care system
• May run up large out-of-pocket expenses for copays, medications, etc
• May get in trouble with employers for missing time for multiple doctor appointments
Assessing for complexity complements assessing for diagnosis.
• Patients with almost any diagnosis can become complex.
•
Level of complexity is often even more relevant than diagnosis to the kind and level of team
structure, care management function, and behavioral medicine or social service involvement.
•
That is, many management challenges for complex patients are very similar across diseases,
knowing that condition-specific protocols and “medical details” vary disease by disease.
•
Assessing for diagnosis and severity is essential, but effective action also requires assessing the
complexity of the patient or case—and acting on that total situation, not only diagnosis and
severity.
Measurement of complexity becomes communication about action, not just description.
(Lyons, 2006)
Assessing for complexity (as well as diagnosis) points to the level and kind of action that needs to
be taken today. This means going beyond providing an accurate description of the patient,
diagnosis, or other state of affairs. Assessment must lead directly to decision-making—especially
what to do today, what to start in motion for follow-up and what doesn’t need to be done at all.
Contrast:
Measurement for precise description vs.
Measurement for action-based communication:
Measurement as mere description
Measurement as action-based communication
To place individual on a trait or diagnostic continuum
To describe an individual for action or service planning
Focus on precision of observations
Focus on caregiver consensus on observations and action
Emphasize scale internal structure and consistency
Emphasize scale clarity, brevity and usability
To be a single definitive source of measurement
To integrate different information across observers
That is, complexity assessment organizes observations into what you are going to do about it.
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Complexity ratings are linked directly to levels of action.
Each item stands on its own—is clinically meaningful and translates into action steps. Rather than
depending entirely on “total scores”, each variable uses the same rating system to decide on level of
action needed:
Assessment of level of action needed
Rating
State of affairs
Level of action needed
0
No complexity—with only routine
care needed
No evidence of need to act (beyond routine care)
1
Mildly complex—basic care planning
needed
Watch / prevent—explore interacting issues
2
Moderately complex—multifaceted
plan needed
Form a well-integrated plan—and set in motion
3
Very complex—intensive care and
planning needed
Immediate, intensive, and integrated action may
be needed
In this approach, the level of action needed results from a combination of both complexity and
severity. This differs from traditional approaches which typically orient only to severity (of
symptoms, risk to life, or functional impairment) but not to complexity.
Note that assessment of complexity takes place regardless of disease and complements assessment
for diagnosis.
Dimensions of complexity assessment:
(A full complexity assessment record appears on page 5)
Current state of affairs
(one question for each point)
• Symptom severity / impairment
• Diagnostic challenge / uncertainty
Action areas
(for complexity-linked care plans)
Responding to symptoms, impairments,
diagnostic uncertainty, threat to life
2. Readiness to engage
• Distress, distraction, preoccupation
• Readiness for treatment & change
Responding to individual or family
distraction or disturbance
3. Social
• Home / residential safety, stability
• Participation in social network
Responding to social vulnerability,
isolation, safety
4. Health system
• Organization of care
• Clinician / patient relationships
Coordinating care, improving
relationships, negotiating for adherence*
5. Resources for care
• Shared language with providers
• Adequacy of insurance for care
Consistency and quality of interpreters
and financial consultation / assistance
Five domains of complexity
1. Illness
(Biomedical, mental health,
substance abuse)
*The degree to which the patient and team have agreed to—and are carrying out—a plan
If assessment of the current state of affairs does not lead to enough confidence for action, past history (last 5
years) can be gathered using the very same domains, i.e., history of:
• Chronicity or diagnostic dilemmas
• Social dysfunction or vulnerability
• Distress and preoccupation with symptoms
• Care system intensity / impaired relationships
A “past history” rating form appears on the “back” of the assessment record (page 6).
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Orientation to Complexity Assessment, 6/25/09
© 2009 University of Minnesota
Working draft
Patient:
Domain
Illness
(Biomedical,
mental health
and substance
abuse sx &
dx)
Readiness
to engage
Social
Health
system
Resources
for care
Minnesota Complexity Assessment Method
University of Minnesota Dept of Family Medicine & Community Health, 4/23/09
Age / gender:
Current state of affairs
Problem:
Complexity level
1. Symptom severity / functional impairment
0=No symptoms—or reversible w/out intense efforts
1=Mild noticeable sx—don’t interfere w function
2=Mod to severe symptoms that interfere w function
3=Severe symptoms impairing all daily functions
2. Diagnostic challenge
0=Diagnosis(s) clear
1=Narrow range of alternative diagnoses
2=Multiple possibilities—clear dx expected later
3=Multiple possibilities—no clear dx expected
3. Distress, distraction, preoccupation
0=None
1=Mild, e.g. tense, distractible, preoccupied
2=Moderate, e.g. anxiety, mood, confusion
3=Severe w behavioral disturbances, e.g., harm
4. Readiness for treatment and change
0=Ready & interested in tx; active cooperation
1=Unsure/ambivalent but willing to cooperate
2=Major disconnect with proposed tx; passivity
3=Major disconnect; defiant/won’t negotiate
5. Home/residential safety, stability
0=Safe, supportive, stable
1=Safe, stable, but with dysfunction
2=Safety/stability questionable—evaluate/assist
3=Unsafe/unstable—immediate change required
6. Participation in social network
0=Good participation with family, work, friends
1=Restricted participation in 1 of those domains
2=Restricted participation in 2 of those domains
3=Restricted participation in 3 of those domains
7. Organization of care
0=One active main provider (medical or MH)
1=More than or less than 1 active provider(s)
2=Multiple medical / MH providers or services
3=Plus major involv. with other service systems
8. Patient-clinician (or team) relationships
0=All appear intact and cooperative
1=Most intact; at least 1 distrustful or remote
2=Several distrustful or remote; at least 1 intact
3=Distrust evident in all pt / clinician relationships
9. Shared language with providers
0=Shared fluency in language with provider
1=Some shared language / culture with provider
2=No shared language; professional transl. available
3=No shared language; family or no translator
10. Adequacy / consistency of insurance for care
0=Adequately insured, can pay for meds, copays
1=Under-insured* with modest other resources
2=Under-or intermittently-insured
3=Uninsured, no other financ. resources for care
No complexity—only routine care needed
No evidence of need to act (beyond routine care)
Mildly complex—basic care planning needed
Watch / prevent—explore interacting issues
Moderately complex—multifaceted plan needed
Form a well-integrated plan—set in motion
Very complex—intensive care & planning needed
Immediate, intensive and integrated action
0
1
2
3
0
1
2
3
Instructions:
As you gather information and listen to the
patient,
• Scan for sources of complexity
(interference with usual care) on the left.
• Ask questions that help you understand
what you don’t know.
• Circle a level that reflects your
understanding of complexity in each
area.
• Outline a plan of action that takes into
account the observed pattern of
complexity
0
1
2
3
0
Plan of action:
General goals:
(for both complexity and diagnosis)
1
2
3
0
1
2
3
Self-check: Do I need someone in this
case with me—and who?
0
1
Team / roles required:
2
3
(who does what—how it adds up)
0
1
Patient / family role:
2
3
(as part of the team)
0
1
What clinician / team will do today:
2
3
(To act on both complexity & diagnosis)
0
1
2
3
0
1
2
3
*Underinsured: Lack of
coverage for hospital,
medications, mental
health; presence of high
deductibles /copays
With all your ratings in view, decide what level
and kind of action is needed in what areas—and
incorporate that into your action plan.
5
Adapted by Peek, Baird, Coleman, & DFMCH faculty with permission
Orientation
Complexity
6/25/09
from,Frits
Huyse, to
C-L
psychiatrist;Assessment,
Dept of General
Internal Medicine;
© 2009
University
Minnesota
Integrated Care, University
Medical
Centre of
Groningen,
The Netherlands.
(Huyse & Stiefel, 2006) Contact: Macaran Baird ([email protected])
© 2009, University of Minnesota
Historical facts and patterns where needed to inform today’s action plan
Draft 4/23/09
Five-year history of risks associated with complexity
History of chronicity and functional impairment (for significant chronic conditions)
Illness-chronicity
rating
0= Less than 3 month dysfunction / impairments
1= More than 3 month or shorter episodes
2=One chronic disease of significance
3=Several chronic diseases of significance
History of diagnostic dilemmas
0=No periods of uncertain diagnosis
1=Diagnosis and etiology quickly clarified
2=Diagnostic dilemma solved with much effort
3=Diagnostic dilemma unsolved despite big effort
History of restrictions in coping or history of distress and preoccupation
Readiness-coping and
distraction
0=No restrictions—manages stress & medical treatment adequately
1=Mild—distress for patient, family, providers
2=Moderate—great distress for all above
3=Severe—serious restriction in ability focus on care or self-care
History of difficulty maintaining interest or readiness for care and treatment
0=None
1=Ambivalence; intermittent readiness for proposed treatment plans
2=Major disconnects or passivity regarding proposed treatment plans
3=Major disconnects, with defiance or seeming unwillingness to negotiate
History of unsafe or stable home / residence
Social
integration
0=None
1=Safe, stable, but with dysfunction, tension
2=Questionable safety or stability
3=Unsafe / unstable
History of social impairment, isolation, or lack of participation
0=None
1=Mild—restrictions in participation; interpersonal problems
2=Moderate—can’t initiate or maintain social relations
3=Severe—disruptive social relations or isolation.
History of intense levels or amounts of treatment or services
Health
system
intensity
and
experiences
0=Less than 4 contacts with physicians per year
1=Four or more contacts per year or 1 specialist
2=Multiple specialists or a hospital admission or involvement with social service systems
3=Several hospitalizations, rehab unit, and social service systems
History of distrustful or distant patient-clinician relationships
0=Full trust and good relationships with providers
1=Some distrust or distance with providers
2=Patterns of distrust and of requests for 2nd opinions or for new doctors
3=Repeated conflicts with doctors or involuntary hospital / rehab admissions
Adapted by Peek, Baird, Coleman, & DFMCH faculty with
permission from,Frits Huyse, C-L psychiatrist; Dept of General
Internal Medicine; Integrated Care, University Medical Centre
Groningen, The Netherlands. (Huyse & Stiefel, 2006)
Contact: Macaran Baird ([email protected])
© 2009, University of Minnesota
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Levels of Application for Complexity Assessment
“Oh my—this will take far too much time!” The complexity assessment tool outlined on previous
pages may elicit that reaction among clinicians and preceptors—until all three levels of application are
seen as available options: Full assessment, shorthand application, and constant mindset.
1. A mental model to always have in mind. Complexity as a factor in care and medical education—
regardless of diagnosis—is a lens to help clinicians and educators more quickly discern patterns in
the exam or precepting room—and hence more quickly formulate actions. A vocabulary and
receptivity for emerging complexity is helpful to have on board all the time—even though most
simple-appearing patient problems are just that—simple.
Clinical demand: All cases—whether simple or complex
Complexity assessment:
From constant mindset to shorthand to full application
Most
Some
A few
A complexity “lens” or mindset to always have in mind
Shorthand complexity assessment in daily practice
Team meetings and case conferences with full complexity assessment
2. Shorthand application in daily practice. Most primary care cases are simple. However, some of
these patients turn out not so simple, particularly when psychosocial stresses or chronic conditions
are involved. As it dawns on clinicians that the case may not be as simple as it initially appeared, a
shorthand application of complexity assessment (or screening) can help quickly focus on what
makes the situation complex and where to investigate further. For example, imagine how a quick
glance at the “pocket card” below could focus the interview questions.
Pocket card: What makes today’s situation start to feel complex—and what do I do about it?
Five domains of complexity
1. Illness and disease
(Biomedical, mental health, S.A.)
2. Readiness
3. Social
4. Health system
5. Resources for care
Current state of affairs
• Symptom severity / impairment
• Diagnostic challenge / uncertainty
• Distress, distraction with symptoms
• Readiness for treatment & change
• Home/residential safety, stability
• Participation in social network
Action areas
Responding to symptoms, impairments,
diagnostic uncertainty, threat to life
Responding to individual or family
distraction or disturbance
Responding to social vulnerability, isolation,
safety
• Organization of care, # of providers
• Clinician / patient relationships
• Shared language with providers
• Insurance resources available for care
Coordinating care, improving relationships,
negotiating for adherence*
Consistency and quality of interpreters and
financial consultation / assistance
*The degree to which the patient and team have agreed to—and are carrying out—a plan
3. Full assessment-- for known complex patients and team meetings. The full assessment is
designed also for preparation and use in team meetings, care conferences, or “collaborative assessment
and planning” visits (Danner) where already-known, tough, time-consuming, difficult, taxing, risky,
puzzling, “overserviced and underserved” or “stuck” cases are taken up.
Such patients are already known to be complex, but the tool helps the team say more than that. “Yes
we know the situation is complex—but how?” The full assessment is a way to structure what could
otherwise be a much more diffuse discussion of complicating factors and what to do about them.
Much time is already being spent on these cases, and if anything, the tool can save some of it.
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Making the observations—the complexity assessment interview
Different observers from different vantage points may gather different observations to be
factored into a complexity assessment. One way is to actually interview a patient with complexity
assessment in mind—and this doesn’t have to be done by a physician*. Here are some sample
messages or questions for such an interview:
• I am __________and would like to better to understand who you are, what you need today and
what we can do to help make your treatment go as well as possible.
[Establishing the purpose of the interchange]
• Can you tell me how you feel about your problem and other concerns you may have about taking
care of it? [Aimed at discovering the patient’s agenda today]
• This is what the doctor told me about your illness. Is that correct? Are there other things I should
know about? Do you feel you understand your medical condition well enough? Do you feel your
doctor understands your situation well enough? Do have any more questions for me?
[Aimed at how the patient understands their condition and doctor understands their situation]
• Who are your other doctors or helpers taking care of you? How do you feel about them and how
have things been going with them? [Aimed at discovering health care system risks for complexity]
• Who do you have at home or family who can help or support you through health problems?
• Now I would like to know something about how you live, your work and social relations and
anything else that affects your condition or situation with it. [Aimed at discovering social risks]
• Now that I know more about your medical and social circumstances, I would like to know how
you like to handle things. Can you tell me how you handle medical problems? How do you handle
pressures, stress, or feeling overwhelmed by life crises or problems when they occur? How do
you handle emotions you find distressing? Is there something going on right now that you are not
sure how you want to handle? Are you someone who finds it easy or hard to follow
recommendations of doctors?
[All these aimed at discovering distress, distraction, and risks to engaging in their own healthcare]
• This is helpful information—useful to us as your healthcare providers. How useful was this to
you? And is there anything else? Anything you think we missed that might be important to your
treatment or how you or your family might handle what is recommended?
*In the Netherlands this interview is often done by a nurse or social work member of the care team. The team calls it “The InterMed
interview”, after the name of the complexity assessment tool (Huyse) that they use and that is adapted here.
Assessment of complexity also has an important place in medical education.
Assessment of complexity and level of action to take today is part of patient care, and arguably equally critical
for medical education, especially precepting.
The point of education is to develop competencies—ability to act in the right way at the right times—and be
able to say why. Students and residents need a patterned response when encountering complex patients that goes
beyond “Oh my—sure is complex”. An approach to assessment that includes complexity (as well as diagnosis)
is critical for medical education and to modernizing the care system.
Residents and students can learn to gather the information they need in caring for complex cases and setting up
teams when needed—using interviewing methods like the one shown above. Preceptors can ask the kinds of
questions of residents and students that prompt the thinking and interviewing “moves” for assessing complexity
and selecting actions that respond to complexity as well as diagnosis.
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Principles for selecting items for a complexity assessment tool;
Context for use of such a tool in a health system
Principles for choosing good items for a complexity assessment tool: (“Clinimetrics”; Lyons)
• Use clear consensus-based language (people can largely agree on what they are looking at)
• Items measure what they appear to measure (face validity)
• Ratings have immediate meaning (affects what is the case and what you need to do about it)
• Minimal redundancy in the items (better to have redundant collection than redundant items)
• Inter-rater reliability is at the item level (since each item means something)
• Subjective states are not measured because sources of observations are severely limited
To this, add principles for involving users in their own item selection (“Communimetrics”; Lyons)
• Involve clinical / organizational partners in selection of items
• Make tools that are malleable to organizational processes
• Include only items that might impact treatment planning: “just enough information” philosophy
• Make the measure easy for clinicians to use
• Make levels of item scoring correspond directly to levels of action
Success factors in incorporating complexity assessment in real care systems
• Uniformity of information (include data collection as part of EMR / IT support of clinical process)
• Structured communication (include proactive “rounds” focusing on clinical mgmt)
• Multidisciplinary (include adjusting team composition to pt needs and venue for care)
• Care chains (include coordination of care, development of care plans)
Larger context in which complexity assessment is situated:
• Active case finding of complex patients (that clinics may or may not already be working with)
• Total Clinical Outcome Management*
Structure: Multidisciplinary—across care venues
Process:
Coordination of diagnosis and communication
Outcomes: Diagnosis-specific, quality of life and costs
• Stepped care (Kroenke): Overlapping and integrated steps-From Patient self-management
to Primary care provider
to Care manager (for primary care provider)
to Collaborative care (more than one provider with or without care manager)
to Referral to specialist
*The concept of Total Clinical Outcomes Management
(In context of Child Adolescent Needs & Strengths tool-CANS; Lyons)
•
•
•
•
Total means embedded in all activities with patient/family as full partners
Clinical means focus is on patient and family health, well-being, function
Outcomes means measures are relevant to decisions about actual or proposed impact of interventions
Management means that this information is used in all aspects of managing the system—all aspects of
care planning, program design, clinical supervision, and system operations.
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Complexity Assessment Pocket Card
(for “shorthand” complexity assessment)
This pocket card is a convenient reminder of
1) The dimensions of complexity and corresponding action areas, and-2) The need to judge level of complexity and corresponding action that may be needed.
The pocket card is used to help shape interviewing in situations when the full-blown complexity
assessment is not being done. This can be especially useful with students and residents as a convenient
way to keep the mindset and basic dimensions of complexity assessment in mind.
Results here may guide action planning or signal that you should do the full-blown complexity
assessment (like “screening” that precedes “assessment”).
Each panel below is one side of the pocket card
(To be cut, folded, and the panels taped to form a two-sided card)
Minnesota Complexity Assessment Method
Current state of affairs
Domains
• Symptom severity /impairment
Illness
(biomedical & MH)
• Diagnostic challenge
Draft 4/09, Univ of MN
Action areas
Responding to sx, impairments;
dx uncertainty; threat to life
Readiness
• Distress, distraction with sx
• Readiness for tx & change
Responding to indiv or family
distraction/ disturbance
Social
• Residential safety, stability
• Participation in social network
Responding to social
vulnerability, isolation, safety
Health system
• Organization of care; # of prov.
• Clinician / patient relationships
Coordinating care, improving
relationships, adherence*
Resources for
care
• Shared language with providers
• Insurance resources for care
Consistency of professional
interpreters; financial
consultation / assistance
*The degree to which the patient and team have agreed to—and are carrying out—a plan
Minnesota Complexity Assessment Method
Level of complexity-linked action needed
State of affairs
0
Level of action needed
No complexity—only routine care
needed
No evidence of need to act
1
Mildly complex--basic care planning
needed
Watch / prevent—
explore interacting issues
2
Moderately complex—multifaceted
plan needed
Form a well-integrated plan—
set in motion
3
Very complex—intensive care &
planning needed
Immediate, intensive, integrated
action needed
(beyond routine care)
Looking at complexity across the dimensions on the other side of the card, decide what level of
action is needed in what areas (using the guide above) and incorporate into your action plan
© 2009 University of Minnesota Dept of Family Medicine & Community Health
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