Continuum Of Care: A Case Study

The successful evolution of this organizational structure in a competitive marketplace has required a close partnership between managers and physicians supported by a culture of physician group accountability for quality and efficiency. An overarching agenda for achieving excellence focuses on high-impact health conditions, provides goal-oriented tools to analyze population data, proactively identifies patients in need of intervention, supports systematic process improvements, and promotes collaboration between patients and professionals to improve health.

Patient-Centered Medical Homes (PCMH) are growing in popularity as the right thing to do improve patient care. PCMH are growing in popularity, as there is early evidence of their effectiveness (Egge, M. 2012). The PCMH concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions. This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the limitations of the current healthcare system (Wang, J. et al 2014). Currently, primary care in the United States is focused on acute and episodic illness, it inadvertently limits comprehensive, coordinated, preventive and chronic care (Bleser, W. et al 2014). The PCMH address these limitations through organizing patient care, emphasizing team work, and coordinating data tracking (Bleser, W. et al 2014). A PCMH and HMO have some similarities but are markedly different.

The fact that there are broad spectrums of services available within the Kaiser Permanente network makes it easier to coordinate patient care. For example the Northern California site has implemented programs that focus on five “imperatives of personal care”, which are: patients have to have a primary care doctor, they need to be able to see that physician, patients that call have a short telephone wait, patients should receive timely appointments and have a great care experience (Commonwealth fund June 2009). Care management definitely plays a crucial role in health care. When the patients needs are met and quality care is received the result is patient satisfaction and potentially cost saving for the organization. Patients not only have to deal with health issues, many experience challenges within their environment and certain limitations depending on socioeconomic status. Therefore , coordination of patient care is key to the success of any health care delivery system.

The Continuum of Care is the variety of health care services provided to numerous individuals who are in need of it. All the various Long Term Care providers work as a unit, helping an individual handle their disability with various health care amenities accessible. The Continuum of Care, as stated in Long Term Care: Managing Across the Continuum (2010), is “comprehensive, integrated, and client-oriented”. All the services offered should be client-based and cater to the client’s needs and suitable care. The client’s should be able to obtain services when it is needed from the provider, making it comprehensive. All the different Long Term Care providers should be interconnected between one another, because their goal is all the same. Their goal is to care for the client’s needs. The Continuum of Care consists of: nursing facilities, sub acute care, assisted living, residential care, elderly housing, and a variety of community-based services (Pratt, 2010). All these different providers work together to care for the individuals within the health care industry, creating the continuum and making it integrated. The continuum has many positive attributes, along with many barriers. The range of barriers are: poor transitions from Long Term Care setting to setting for the clients, the continuum is reimbursement-driven, it is fragmented and uncoordinated, it is under staffed with medical professionals, and there are major language and literacy problems.

Berry, L., Rock, B., Houskamp, B., Brueggeman, J., & Tucker, L., (2013). Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clinic Proceedings, 88(2), 184-94. Retrieved from http://search.proquest.com/docview/1312503895?accountid=34574

In some areas of population health, technology in enhanced patient information is utilized to perform risk stratification to identify the high risk patients. These patient’s often have uncontrolled BP, diabetes with an HgbA1c over 9, COPD, etc. Once identified as high risk or potential high risk, these patients receive additional care or patient outreach to help manage their condition. Some organizations employee RN Health Coaches and Care Coordination teams to help these patients and identify gaps in care. The primary care physician assumes care of the patient along with striving for the patient to become active in their overall health thereby keeping them out of the hospital (Sanford, 2013). One enhanced area of population management is the PCMH model. PCMH practices increase patient’s engagement in shared decision making while providing compensation for care coordination, care management and medical consultation outside of traditional face-to-face visits (Berryman, Palmer, Kohl &Parham, 2013). A patient centered approach pushes for changes not only in the delivery of medicine but in traditional encounters. In addition, PCMH encourages increased access to the patient’s primary care physicians and improved patient satisfaction scores. PCMH and population health encourages providers to increase after hours care to decrease emergency department visits and/or hospitalizations. Thereby reducing cost and improving the patient’s

Long-term care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability. Long-term care helps meet health or personal needs. Most long-term care is to assist people with support services such as activities of daily living like dressing, bathing, eating, and using the bathroom. Long-term care can be provided at home, in the community, in assisted living or in nursing homes. Long-term care can be given at any age depending on

“All health care disciplines share a common and primary commitment to serving the patient and working toward the ideal of health for all.” (American Association of Colleges of Nursing, 2014, p. 1) There are many different professional members in the healthcare system. Each of them, have a specific specialty and responsibility to the patient and play an important role in the patient’s overall plan of care. “The scope of health care mandates that health professionals work collaboratively and with other related disciplines. Collaboration emanates from an understanding and appreciation of the roles and contributions that each discipline brings to the care delivery experience.” (American Association of Colleges of

Burns, L. R., Bradley, E. H., Weiner, B. J., Shortell, S. M., & Kaluzny, A. D. (2012). Shortell and Kaluzny's health care management: Organization, design, and behavior (6th ed.). Clifton Park, NY: Delmar Cengage Learning.

In Clinical Integration in Strategic Planning “providers can track the patient across the continuum, coordinate care across the continuum and make sure the patient is getting the most appropriate care in the most appropriate environment” (Karash & Larson, 2016). It is needed to simplify the direction/coordination of patient care through any circumstances, providers, sceneries, and time in order to attain care that is harmless, appropriate. effectual, well – organized, reasonable and patient-focused. In addition, clinical integration also develops the partnership with the physician, an administrator developing the partnership with the team. Clinical integration starts from the top board of

There are three core principles to any ACOs. First, provider-led organizations with primary maintenance and a strong base are liable communally and total per capita costs for quality with full continuum for the population of care for patients. Second, excellent improvements will have linked to also have complete costs reduced, and third, progressively and reliable sophisticated measurement performance to improve, support, and provide the savings of confidence are achieved with improvements of care, , McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES (2010).

The American health care system has been victim to an escalation in the prices of health care services juxtaposed with inefficiency in delivery of care services. There has even been cases where State spending on the actual health care increased dramatically in the United States and one of the key components of curbing this problem which has been prevalent over the mass media and has been a major discussion among physicians is the advent of Accountable Care Organizations. Accountable Care Organizations (ACOs) is structured with the goal of trying to improve health care delivery and aid in the reduction of the overall cost of services (Weissert & Weissert, 2012). If there is insufficient coordination of high quality care delivery in the health care industry, this will have a negative impact on patient safety and diminish affordable care for patients. Hence, the development of ACOs is envisioned to be the savior of medical practices and can improve the overall fabric of the American society (Bresnick, 2013). ACOs serves as one of the answers for curbing the problem of high costs, low quality care and possible segmented delivery and as much as it serve as the major determinant for improvement in patient satisfaction, there are minor

The current health care sector is too costly and too fragmented with a lot of variation in care even with established evidence based guidelines. Providers lack the tools, support and information they need to offer the coordinated health management that can reduce cost and improve outcomes. Primary Care Physicians are constrained in their abilities to perform any proactive care that involves avoiding Hospital or ER visits, and influencing healthy lifestyles.

In the United States, our health care system is often characterized by communication failures. According to the American Nurses Association (2012), “Care coordination has been proposed as a solution to many of the seemingly intractable problems of American health care: high costs, uneven quality, and too frequent disappointing patient outcomes” (para. 14). Care coordination is a very important aspect in nursing roles and is extremely valuable because it can improve outcomes for everyone: patients, payers, and providers. Although it is obvious that the changes will improve patient care and general efficiency, applying changes in the general approach and everyday routines may be overwhelming. Luckily, there are resources available for those interested in taking a more coordinated approach to primary care practice (“Social Media’s leading Physician Voice,” 2012).

Teamwork is vital in healthcare.  When all participants are engaged in a program, goals are successfully achieved. Being able to communicate and work collectively as a team requires an appreciation for each other’s area of practice.  Every team member has an important role and being acknowledged provides a sense of responsibility and accountability. Essentially, inter-professional collaboration helps ensure that the patient is getting care that is not only accessible but also comprehensive.  The plan of a patients’ care includes active participation by all health care professionals working interdependently in accordance to the patient’s preferences, values and beliefs. The health care team accomplishes the goal of meeting the patient’s medical needs by delivering evidence-based practice.   To deliver quality care, the patient should always be involved.