Complex Care and Contradictions of Choice in the Safety Net

Van Natta M, Burke NJ, Yen IH, Rubin S, Fleming MD, Thompson-Lastad A, Shim JK
Source: Sociol Health Illn
Publication Year: 2018
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Complex care, Vulnerable/disadvantaged
Demographic Group: Urban
Intervention Type: Service redesign
Study Design: Other Study Design
Type of Literature: White

This article explores the complicated and often-contradictory notions of choice at play in complex care management (CCM) programs in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety-net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilizers into ‘active’ patients who will reduce their service utilization and thereby contribute to a more rational, cost-effective healthcare system. By considering our data alongside philosopher Annemarie Mol’s (2008) conceptualization of the competing logics of choice and care, we argue that these premises often undermine CCM teams’ efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio-economic barriers as well. We assert that while safety-net CCM programs are held accountable for the degree to which their patients successfully transform into self-managing, cost-effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programs thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at:

Insights Results

Overview of article

  • This paper explores the complicated and often-contradictory notions of choice at play in Complex Care Management (CCM) programs in the U.S. healthcare safety net

Methods of article

  • This qualitative investigation draws from an ongoing multi-method study aiming to understand the processes and structures through which CCM programs at 2 safety-net sites address their patients’ social and medical needs. The safety-net sites in this study were located in major urban areas
  • Clinic 1 began in early 2012 and included an adult medicine clinic and a family health clinic at a public hospital. A nurse and health coach dyad worked in close collaboration with other providers outside the program, including primary care providers and social workers. Patients identified as at high risk for frequent hospitalizations and who did not receive intensive case management services elsewhere were eligible for enrollment. ‘High risk’ included any1 with multiple chronic co-morbidities who had at least 3 hospitalizations and/or ED admissions within the past 12 months. Initial enrollment criteria evolved and became more complicated over the course of the study
  • Clinic 2 launched in January 2013 at another public hospital. It was more interdisciplinary than Clinic 1 but had similar enrollment criteria
  • Both programs aimed to reduce hospitalizations, improve self-management among enrollees, and graduate them once these goals were met
  • 4 ethnographers (2 at each site) conducted observations of patients and providers in the clinic, patients’ homes, and other settings. The ethnographers shadowed participants during their day-to-day interactions in order to understand clinic flows and processes. Observations of patients focused on institutional health literacy and the ways in which team-based care sought to develop effective trust and communication, self management, and engagement strategies with patients. Observations of providers and clinic staff involved tracing interactions with patients, workflow and communication systems, and problem-solving in the CCM context
  • Ethnographers also conducted interviews with the 108 patients and providers observed. In-person, semi-structured interviews probed for information on patients’ experiences in the CCM program and thoughts about their past, present, and future health
  • The ethnographers also conducted 2 waves of semi-structured interviews with 48 CCM providers and staff. Interviews related to providers’ and staff’s interactions with various departments within and beyond their respective institutions, perspectives on the goals and impacts of CCM programs, processes of patient enrollment and progress, and challenges to providing care


  • Many patients faced combinations of poverty, housing and food insecurity, substance use, mental illness, limited cognitive capacity, and inadequate social support. Additionally, patients reported distrust and/or lack of confidence in healthcare and other social services
  • Patients and CCM teams struggle to reconcile the imperative for individual choice and responsibility and the realities of systemic neglect, especially in the day-to-day reality of safety-net health care
  • The logic of choice often proved counter-productive to caring for patients in situations characterized more by systemic neglect than consumer choice. The care teams therefore oscillated between the logic of choice and the logic of care as they carried out their difficult everyday work amidst rampant neglect
  • The lives of many patients observed reflected a stark lack of care. This was not a lack of care by CCM teams, but rather systemic neglect at multiple levels of patients’ everyday life, manifested as discrimination, limited employment and housing opportunities, insufficient mental health and drug rehabilitation support, and an absence of stable social support

Key takeaways/implications

  • The study concludes that the idea of patient-as-consumer is untenable even in a privatized healthcare context, because it seldom resembles a ‘free’ market; in the world of the healthcare safety net, then, patients could not be further away from the ideal of the rational healthcare consumer. This should be considered in future research on how patients are viewed as consumers
  • The frustration that patients and providers encountered in relation to the ambivalent and contradictory invocation of choice illustrates the mismatch between the logic that undergirds how patients can improve and self-manage their own health and the daily realities of systemic neglect. The actions of both patients and CCM teams explicitly challenged the premises of patient activation and revealed the complex interplay of individual, institutional, and structural contexts, and yet CCM patients and providers continued to be measured against personalized parameters that judged the quality of patients’ choices