GBAM/501 Read Me First - University of Phoenix



Read Me First HCS/235

Week Four

INTRODUCTION

The structure of the U.S. health care system is complex and fragmented. Navigating the system to achieve maximum health outcomes is challenging for most consumers. Two concepts designed to overcome barriers to quality health care are the continuum of care and continuity of care. The continuum of care refers to the variety of health care services across the life span. Continuity of care refers to provider and informational consistency within those services. Integrated delivery systems are health care delivery entities working together to promote continuity and coordination of care across the health care continuum.

Continuum of Care

THE HEALTH CARE DELIVERY COMPONENTS IN THE PUBLIC AND PRIVATE SECTOR HEALTH CARE SYSTEMS PROVIDE SERVICES FROM PRECONCEPTION TO DEATH RESULTING IN A LIFETIME CONTINUUM OF HEALTH CARE SERVICES. HEALTH SERVICES ARE AVAILABLE FOR EVERY STAGE OF LIFE, HEALTH, AND EVEN DEATH. YOUR TEXTS ORGANIZE THE HEALTH SERVICES DELIVERY SYSTEM INTO PRIMARY, SECONDARY, TERTIARY, LONG-TERM, AND PALLIATIVE CARE. WITHIN THAT FRAMEWORK, HEALTH CARE DELIVERY SERVICES CAN BE CATEGORIZED AS AMBULATORY, ACUTE, OR LONG-TERM.

AMBULATORY CARE, SUCH AS VISITS TO A PHYSICIAN’S OFFICE, IS DEFINED AS CARE THAT DOES NOT INVOLVE ADMISSION TO AN INPATIENT FACILITY. PREVENTIVE CARE SUCH AS IMMUNIZATIONS OR SCREENING, WELLNESS EXAMS, AND OTHER ROUTINE CARE ARE PART OF THE AMBULATORY CARE DOMAIN. MEDICAL AND SURGICAL PROCEDURES PROVIDED IN OUTPATIENT FACILITIES ALSO ARE CONSIDERED AMBULATORY CARE. ACUTE CARE GENERALLY REFERS TO EMERGENCY OR SHORT-TERM INPATIENT CARE IN A TEACHING OR COMMUNITY HOSPITAL. LONG-TERM CARE SERVICES ARE PROVIDED IN SKILLED NURSING FACILITIES, NURSING HOMES, ASSISTED-LIVING FACILITIES, AND REHABILITATION CENTERS. THESE FACILITIES PROVIDE NURSING CARE AND OTHER SOCIAL SERVICES TO PATIENTS WHO DO NOT REQUIRE HOSPITALIZATION BUT CANNOT FUNCTION INDEPENDENTLY.

OTHER FORMS OF HEALTH CARE DELIVERY SERVICES ACROSS THE CONTINUUM INCLUDE HOME HEALTH CARE AND PALLIATIVE CARE. HOME HEALTH CARE AGENCIES PROVIDE NURSING SERVICES OR THERAPY IN THE HOME TO INDIVIDUALS WHO DO NOT NEED TO BE INSTITUTIONALIZED, BUT DO NEED SPECIALIZED CARE. PALLIATIVE CARE PROVIDES SERVICES TO IMPROVE THE QUALITY OF LIFE OR MANAGE PAIN FOR PEOPLE WITH LONG-TERM DISABILITIES, CHRONIC CONDITIONS, OR WITH TERMINAL ILLNESSES. FOR PEOPLE IN THE LAST PHASE OF LIFE, THE SPECIFIC PALLIATIVE SERVICES ARE KNOWN AS HOSPICE CARE. PALLIATIVE OR HOSPICE SERVICES CAN BE PROVIDED IN THE HOME OR IN A FACILITY.

THE MENTAL HEALTH CARE SYSTEM PROVIDES A VARIETY OF SERVICES TO INDIVIDUALS WHO HAVE EITHER AN ACUTE OR CHRONIC MENTAL ILLNESS. TREATMENT FOR THOSE PEOPLE WHO HAVE A MENTAL ILLNESS HAS SHIFTED FROM LONG-TERM INSTITUTIONALIZATION TO AMBULATORY TREATMENT IN COMMUNITY MENTAL HEALTH CENTERS. MENTAL HEALTH CARE IS PROVIDED IN INPATIENT AND OUTPATIENT SETTINGS. THE INTEGRATION OF PHYSICAL AND MENTAL HEALTH CARE SERVICES IS CHALLENGING AND OFTEN OVERLOOKED.

CONTINUITY OF CARE

WHILE THE CONTINUUM OF CARE, AS DESCRIBED IN YOUR TEXTS, REFERS TO THE RANGE OF HEALTH SERVICES MEETING MANY NEEDS THROUGHOUT THE LIFE SPAN, CONTINUITY OF CARE USUALLY REFERS TO THE CONSISTENCY BETWEEN THE HEALTH CARE PROVIDER AND THE PATIENT. CONTINUITY OF CARE ALSO REFERS TO THE AVAILABILITY OF COMPREHENSIVE PATIENT INFORMATION, ASSURANCE OF KEPT FOLLOW-UP APPOINTMENTS, AND SEAMLESS TRANSITIONS FROM ONE HEALTH CARE SETTING TO ANOTHER.

LACK OF CONTINUITY AND COORDINATION OF CARE BETWEEN DIFFERENT LEVELS AND SETTINGS OF CARE DUE TO FRAGMENTATION IS APPARENT IN DUPLICATION OF SERVICES AND INFRASTRUCTURE, UNUSED RESOURCES OR CAPACITY, HEALTH CARE THAT IS NOT PROVIDED AT THE MOST APPROPRIATE LOCATION, SUCH AS A PROCEDURE THAT COULD BE HANDLED IN AN OUTPATIENT FACILITY IS PERFORMED IN A HOSPITAL, SERVICES THAT DO NOT COVER THE RANGE OF SERVICES IN THE HEALTH CARE CONTINUUM, OR SERVICES THAT DO NOT FULLY MEET PATIENTS’ NEEDS (WHO, 2008A).

RESEARCH SHOWS THAT CONTINUITY OF CARE SEEMS TO IMPROVE THE QUALITY OF CARE IN MANY WAYS. IMPROVEMENTS HAVE BEEN SHOWN IN PATIENT SATISFACTION, EARLY DIAGNOSIS, IMPROVED COMPLIANCE, AND REDUCED RESOURCE CONSUMPTION (VAN SERVELLAN, FONGWA, & MOCKUS D'ERRICO, 2006). HOSPITALIZATION AND EMERGENCY ROOM USE DECREASES AND THE USE OF PREVENTIVE SERVICES INCREASES AS PATIENTS HAVE BETTER ACCESS TO OUTPATIENT SERVICES.

THE CONSISTENT AVAILABILITY OF PATIENT INFORMATION OR HEALTH RECORD CONTINUITY THROUGH ELECTRONIC HEALTH RECORDS IMPROVES CARE BY INCREASING THE PROVIDER’S KNOWLEDGE OF THE PATIENT. PATIENT SATISFACTION IS INCREASED WHEN THE HEALTH CARE PROVIDER REMAINS CONSTANT. CONTINUITY OF CARE IS ESPECIALLY SIGNIFICANT FOR PATIENTS WITH CHRONIC DISEASES.

CASE MANAGEMENT, CARE COORDINATION, AND CARE MANAGEMENT ARE SIMILAR PROCESSES DEVELOPED TO IMPROVE THE CONTINUITY OF CARE. THE NAMES OF THE PROCESSES ARE USED INTERCHANGEABLY BY SOME— DEPENDING ON THE PERSPECTIVE OF THE PROVIDER. CASE MANAGERS, CARE COORDINATORS, AND CARE MANAGERS IDENTIFY AND COORDINATE ALL HEALTH, PSYCHOLOGICAL, AND SOCIAL SERVICES NEEDED TO MEET THE CONSUMER’S NEEDS. MEETING THE CONSUMER’S NEEDS PROMOTES BETTER OUTCOMES.

INTEGRATED DELIVERY SYSTEMS

WHAT HAS CAUSED FRAGMENTATION OF THE AMERICAN HEALTH CARE SYSTEM? THERE ARE MANY CONTRIBUTING FACTORS IN HOW HEALTH CARE HAS EVOLVED IN THE UNITED STATES. ONE IS INSTITUTIONAL SEGMENTATION, WHERE THE MAJORITY OF PROVIDERS OPERATE INDEPENDENTLY. BECAUSE HEALTH AUTHORITY IS DELEGATED DOWN TO LOCAL LEVELS IN AMERICA, THERE IS DECENTRALIZATION UNDER DIFFERENT ADMINISTRATIVE ENTITIES IN THE PUBLIC, PRIVATE, AND VOLUNTARY SECTORS.

THE PREDOMINANT CARE MODEL IN THE UNITED STATES IS STILL ACUTE CARE AND HOSPITALIZATION, AS OPPOSED TO A PREVENTIVE MODEL; PUBLIC HEALTH SERVICES ARE LARGELY SEPARATED FROM PERSONAL CARE. THIS STRUCTURE HAD LED TO A VERTICAL DESIGN OF SERVICE DELIVERY WHERE INDIVIDUAL PROVIDERS ARE FOCUSED ON TARGETING SPECIFIC RISKS, DISEASES, OR POPULATIONS RATHER THAN SERVING THE PATIENT HOLISTICALLY. THE MULTIPLICITY OF HEALTH CARE PAYERS AND PAYMENT MECHANISMS IS ALSO A CAUSE OF FRAGMENTATION, AS WELL AS LEGAL AND ADMINISTRATIVE OBSTACLES (PAHO/WHO, 2011).

INTEGRATED DELIVERY SYSTEMS (IDS) ARE A TREND IN HEALTH CARE AIMED AT COUNTERING THE NEGATIVE EFFECTS OF FRAGMENTATION IN THE AMERICAN HEALTH CARE SYSTEM. IDSS OPERATE AT AN ORGANIZATIONAL OR ADMINISTRATIVE LEVEL TO IMPROVE CONTINUITY AND COORDINATION OF CARE FOR PATIENTS. SPECIFICALLY, THE GOAL OF AN IDS IS THE MANAGEMENT AND DELIVERY OF HEALTH CARE IN A COMPREHENSIVE AND INTEGRATED WAY SO PEOPLE HAVE ACCESS TO AND RECEIVE A CONTINUUM OF HEALTH PROMOTION, PREVENTION, DIAGNOSTIC, TREATMENT, DISEASE MANAGEMENT, REHABILITATION, AND PALLIATIVE CARE SERVICES THROUGH THE VARIOUS LEVELS AND SITES OF CARE, ACCORDING THEIR NEEDS THROUGHOUT THEIR LIFE COURSE (WHO, 2008A).

INTEGRATION CAN MEAN ALL SERVICES ARE PROVIDED AT ONE LOCATION, BUT MORE OFTEN, IT ENTAILS MULTIPLE PROVIDERS COLLABORATING TO SOME DEGREE TO MANAGE PATIENT CARE EFFECTIVELY AND EFFICIENTLY (MONTENEGRO ET AL., 2011).

THE OLDEST EXAMPLE OF AN IDS OR HORIZONTAL SYSTEM DESIGN IS THE CAPTIVE GROUP MODEL HEALTH MAINTENANCE ORGANIZATION, SUCH AS KAISER PERMANENTE. IN THIS STRUCTURE, ALL LEVELS OF CARE AND SERVICES ARE PROVIDED AND COORDINATED IN ONE LOCATION OR IN CLOSE PROXIMITY. SPECIFICALLY, THE KAISER MODEL REPRESENTS HORIZONTAL INTEGRATION, WHERE SIMILAR LEVELS OF CARE ARE LINKED, AS IN CROSS-FUNCTIONAL TEAMS; AND VERTICAL INTEGRATION, WHERE DIFFERENT LEVELS OF CARE, AS IN PRIMARY, SECONDARY AND TERTIARY CARE, ARE ADMINISTRATIVELY CONNECTED.

Accountable care organizations represent another kind of integrated delivery system, as they are “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients” (CMS, 2012, para. 1). This incentive program was created by the Patient Protection and Affordable Care Act in 2010. Participating providers who succeed in delivering high-quality and resource efficient care are eligible to retain part of the savings achieved for the Medicare program.

Finally, the concept of the medical home is another trend in health care toward creating an IDS in one health care setting, where primary care is centered around patients. The World Health Organization defines people-centered care as care focused and organized based on the health needs and expectations of patients, their families, and communities rather than on diseases (WHO, 2008a). The National Center for Quality Assurance, a major health care accrediting body, created a certification called the Patient-Centered Medical Home, which measures specific criteria around patient-centered care, teamwork, and coordinating and tracking care over time (NCQA, 2012).

This week in relationship to the course and the program

LAST WEEK, YOU EXAMINED THE ORGANIZATION OF THE U.S. HEALTH CARE PUBLIC AND PRIVATE SYSTEMS IN THE CONTEXT OF STAKEHOLDERS. YOUR READINGS AND LEARNING TEAM ASSIGNMENT ELABORATE ON THE SERVICE DELIVERY COMPONENTS ALONG LIFE’S CONTINUUM IN THAT ORGANIZATION.

HINTS FOR A READING STRATEGY OF THE ASSIGNED MATERIALS

AS YOU READ, THINK ABOUT THE HEALTH CARE FACILITIES IN YOUR COMMUNITY OR REGION AND HOW THEY ARE ALIGNED WITHIN THE CONTINUUM OF CARE. ARE THERE GAPS? IS THE CONTINUITY OF CARE COMPROMISED? PUT YOURSELF IN THE POSITION OF A HEALTH PLANNER FROM THE PERSPECTIVE OF THE CONSUMER AND THE HEALTH CARE PROVIDER WHEN PLANNING NEW HEALTH CARE SERVICES. READ THESE MATERIALS WITH THE KNOWLEDGE THAT THE POPULATION IS AGING, RESULTING IN AN INCREASED INCIDENCE OF CHRONIC DISEASES TO BE MANAGED. THINK ABOUT TECHNOLOGY AND HOW IT CONTRIBUTES TO OR INHIBITS CONTINUITY OF CARE.

SOME QUESTIONS TO ASK AS YOU HONE YOUR CRITICAL THINKING

AS YOU REVIEW YOUR READINGS AND RESEARCH THE LITERATURE FOR YOUR LEARNING TEAM ASSIGNMENT, CONSIDER THE FOLLOWING QUESTIONS:

• HOW DO MANAGED CARE MODELS CONTRIBUTE TO THE CONTINUUM OF CARE?

• TO WHAT EXTENT IS COLLABORATION AMONG HEALTH CARE SERVICE DELIVERY COMPONENTS NECESSARY FOR CONTINUITY OF CARE? WHAT WOULD COLLABORATION LOOK LIKE?

• HOW DO INDIVIDUALS TRAVEL ALONG THE CONTINUUM OF CARE? IS IT A LINEAR PROGRESSION FROM ONE COMPONENT TO THE NEXT? WHY OR WHY NOT?

SUMMARY

WEEK THREE PRESENTS YOU WITH AN EXAMINATION OF VARIOUS HEALTH CARE DELIVERY ENTITIES IN HEALTH CARE. COLLABORATION AMONG HEALTH CARE AGENCIES, PROVIDERS, AND CONSUMERS IS ESSENTIAL FOR ACHIEVING AN INTEGRATED SERVICE DELIVERY NETWORK AND CONTINUITY OF CARE. HEALTH CARE MANAGERS AND ADMINISTRATORS ARE IN A POSITION TO FACILITATE LINKS AMONG THESE ENTITIES.

REFERENCES

CENTERS FOR MEDICARE AND MEDICAID SERVICES. (2012). ACCOUNTABLE CARE ORGANIZATIONS (ACO). RETRIEVED FROM

Montenegro, H., Holder, R., Ramagem, C., Urrutia, S., Fabrega, R., Tasca, R., & ... Gomes, M. A. (2011). Combating health care fragmentation through integrated health service delivery networks in the Americas: lessons learned. Journal of Integrated Care, 19(5), 5-16.

Pan American Health Organization/World Health Organization (PAHO/WHO). (2011). Integrated health service delivery networks: Concepts, policy options and a road map for implementation in the Americas. Retrieved from

VAN SERVELLEN, G., FONGWA, M., & MOCKUS D’ERRICO, E. (2006). CONTINUITY OF CARE AND QUALITY CARE OUTCOMES FOR PEOPLE EXPERIENCING CHRONIC CONDITIONS: A LITERATURE REVIEW. NURSING & HEALTH SCIENCES, 8(3), 185–195.

WHO. (2008). INTEGRATED HEALTH SERVICES – WHAT AND WHY? TECHNICAL BRIEF NO. 1. RETRIEVED FROM

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