Monday, 24 September 2018

The problem is the persistence in fragmentation

The model of health services provision is a combination of professional bureaucracy and political-administrative bureaucracy, passed through the filter of organizational rationalization. The fact is that a third (approximately) of clinical processes adapts well and logically, show good results. Let's say: programmed surgical interventions, acute medical pathologies of low-medium complexity, stroke code or heart attack code. So far so good, but it’s inescapable that there are two thirds of the case-mix that don’t fit with the rigidities of what’s offered; we speak, logically, of chronic disease and geriatric frailty, but also of degenerative diseases when they begin to be limiting in the clinically complex processes of difficult labelling. Additionally, in society there are a lot of people in delicate situations, maybe they live alone, maybe they are poor or immigrants or maybe because they live in unstructured environments, to give four examples; people who either don’t access the services or, if they do, they don’t know what to make of them.

Unmistakable signs of the evils of fragmentation

At this point, I won’t surprise you with the five signs of the evils of the fragmentation that I have chosen, but I have to admit that if we put them together they impress:

1) Every morning, at the time of the changing of the guard, all emergency services begin the day with a queue of people waiting for admission. These are patients not well enough to return home, but they don’t have sufficient appeal for the medical services that control the entry criteria, according to the particular point of view of their specialty.

2) In the hospitalization floors there are always remnants of hospitalized people who have already been discharged from the hospital, but can’t leave for example because their daughter says that she can’t take the parent home, or patients who cannot leave because they don’t have a caregiver, which is a necessity after the latest setback. This would be the typology of so-called, in a derogatory way, bed blockers.

3) Radiologists and analysts don’t know what to do to curb the prescribing anxiety of clinicians, since many of them have forgotten the principles of clinical reasoning and have taken refuge in defensive medicine or in the hunting of zebras in Texas.

4) The disorder in the treatment of chronic patients causes that, on the one hand, many to be polymedicated, while, on the other, adherence to the recommendations is below 50%, which is a clear sign that many doctors don’t know anything about their patients' condition.

5) Many specialists, lacking in global vision, don’t like to present the end-of-life processes in a sincere and open manner to their patients. The result is that patients with chimiotherapeutic treatments continue to die in hospitals, when they could have benefited from palliative care, which in all likelihood would be much more appropriate.

Plans to overcome fragmentation are clearly insufficient

For many years now, proposals have been brought forward to help combat the evils of fragmentation, such as: offer of social and health services, acute geriatric units, day hospitals, home hospitalization, discharge transfer programs, emergency units for elderly people, palliative care units, etc. On the other hand, there is a dynamic of many agencies and publishers to promote value clinical practices (you can visit the label "right care" in this blog). These initiatives, and others in this line, despite heading in the right direction, don’t question the status quo; they only fulfil a decompression or recommendation function.

No sector of the economy could survive such a large mismatch between supply and demand, but as George Halvorson said, we must not wait for the health system to reform itself and, precisely, due to this inability to rethink what they do, the health systems are in permanent tension. So how do they survive? Well, apparently, there are three possible paths they take depending on the circumstances of each country: a) create deficit, b) increase budgets or c) increase policies.

What should we do?

We should forget reforming the offer with patches and instead rethink what we do from the perspective of understanding the real needs of people. With the aim of helping, I offer five initiatives that, initially, only require investment in training:

1) Motivational interview and shared clinical decision. The clinical professionals must overcome the phases of informing, training and educating, and instead must learn to conjugate the verbs to listen, understand and imply. There is still limited evidence regarding the effectiveness of this change, but as Víctor Montori says, it’s an obligation of modern medicine to value its practices.

2) Comprehensive geriatric assessment has shown, in a meta-analysis, that it reduces in-hospital mortality and readmissions. The comprehensive geriatric assessment is a dynamic and structured diagnostic process that allows detection of the problems, needs and capacities of the elderly in the clinical, functional, mental and social spheres. Given these good results, all clinicians who treat older people, of any specialty, should receive training in comprehensive geriatric assessment.

3) Individual care plans in multidisciplinary team environments. Professionals of all specialties should be prepared to align assistance objectives in a group manner, and achieve a proportionate use of community, social and health resources according to the needs of each person.

4) Palliative care should be practiced in all the circumstances in which it’s indicated. For this, it will be necessary to specifically train all the medical specialists and nurses, in a manner adjusted to the type of patients they treat.

5) Waste due to low value clinical practices. It must be fought through training but also by promoting value-based financing models.

Healthcare structures today, at least in two thirds of what they do, are as ineffective as they are resistant to innovation. That is why we must concentrate on changes in the attitude of professionals, which means investing in training, in addition to having the courage to rethink the whole organization based on the value that is provided. Sounds utopian? Buurtzorg and Kaiser Permanente, in two very complex environments, have achieved it.

Jordi Varela

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