Aligning care objectives

In last week’s post, I was showing you the benefits of coordination and the difficulties of integration but only in terms of organizational models, of course. However, now I believe it’s time to enter another innermost level, the clinical process, and for this reason I want to emphasize that regardless of models, aligning care objectives is the key step to improving clinical outcomes. To illustrate what I mean, I thought of an example. Imagine an emergency doctor responding to a person suffocating and, as it can not be otherwise, his goal should be in reducing the clinical problem and helping the patient to recover his normal breathing as soon as possible. But if it turns out that the patient is a complex chronic, the issue is that the doctor should also bear in mind that his action should be performed by the wagnerian chronicity model: What are the circumstances of this patient? Does he live alone? How many relapses has he had lately? Is there a professional team that takes care of him continuously? Can I contact them? From the answers to these questions will depend that the undertaken actions after diuretics and oxygen, are really effective and that the system holistically is able to improve the quality of life of that person.

For those who are not used with the terminology and with the concepts of chronicity, allow me a brief reminder of the model "Chronic Care Model" attributed to Edward Wagner, Director Emeritus of McColl Centre for Health Care Innovation:

See how the emergency doctor (we continue with the case of the patient who goes to the emergency room because he is suffocating) should act as part of an individualized treatment plan that should involve resources that are usually employed in the community, such as in social services and primary health care, but especially in the nearest environment, family and caregivers. Also, among all the actors of the treatment plan, it should be clear that the most important goal is to help the patient understand his illness (self-management support), know how to prevent crises and learn how to manage the symptoms and signs in as far as possible.

After this long introduction, the focus of this post is to explain that there are two very different ways of advancing towards the alignment of objectives:

Extraordinarily conventional programs: those that we call "codes" that are really conventional in relation to what is usual in the health sector. All professionals that at any a given time, are attending a patient bearing the label of stroke code or myocardial code or of a process of organ donation with subsequent transplantation know that they need to act according to a well thought out action plan, also know they are forced to do things in a certain way, regardless of the company that pays their wages or the local health care model. These programs are giving results so extraordinarily good that are difficult to replicate in other illnesses.

Individualized care plans (ICP). For the pathologies that are not likely to be standardized, which constitutes the majority, but that require a lot of coordination of various professionals, the ICP is the primary instrument, but for it to work properly, the ICP should be drawn in multidisciplinary team meetings to which everyone that has something to do with the care process should be able to have a say, so that afterwards they can perform the action that it’s attributed to them.

Alignment of care objectives is the basic clinical instrument for addressing clinical processes for complex patient, but do not forget that this is an element that requires well led and cohesive multidisciplinary teams.


Jordi Varela

Editor