Cross-functional units, a challenge within reach

Jordi Varela

Editor

In 2003, a study led by Chris Ham observed that for eleven clinical situations related to chronicity and age, the NHS allocated up to three and a half times more hospital beds than Kaiser Permanente. This was such a surprising result that it generated great admiration for the European health managers by the Californian insurer, especially considering that, according to the researchers themselves, the success of KP lies in the transversal integration of its services, the promotion of self-care, the active role of community nurses and the involvement of physicians to achieve maximum resolution of problems in the framework of primary care.

Getting inspired by KP is paramount

In light of the evidence, health organizations must carry out a planning exercise based on three points: a) identify, in the field of primary care, people affected by the most frequent chronic diseases: type 2 diabetes, heart failure, COPD, coronary artery disease, high blood pressure, depression-anxiety, cognitive problems and osteoarthritis, to name the most common; b) agree on a clinical path between primary care and the corresponding hospital specialists, specifically determining "who does what" and evolve it towards a "value chain", and c) generate a cross-functional collaborative unit (CFCU) that acts as a single reference for the primary care teams (PCT) for each of the flows generated by the chosen clinical processes.

Agenda to be resolved to make the KP experience a reality

1. The diagnostic and assessment process of suspected cases should be carried out with a joint effort between the PCT and the corresponding CFCU.
2. The primary and secondary prevention of each of the pathologies should fall mainly on the PTC since primary care is the most appropriate level of care to promote healthy habits in the population at risk, adjust treatments to the way of being of each person, promote shared clinical decisions, improve adherence to recommendations, strengthen home controls in the most vulnerable patients, establish cooperation networks with neighbourhood pharmacists and develop surveillance systems to detect decompensation early.
3. The competencies of family and community nurses must be deployed to the maximum, so the formative and evaluative support of the specialized nurses of the corresponding CFCU will be necessary.
4. The clinical sessions, the qualified consultations and the training programs carried out between the CFCU and the PCTs must be the basis for continuous improvement and updating of knowledge.
5. Family doctors and CFCU specialists must fully share the diagnostic and therapeutic guidelines, to indicate medical or surgical treatments according to the evidence, and also adjust them to the characteristics of each person.
6. Family doctors, family nurses and primary care pharmacists should periodically review the medication that patients take and propose de-prescription strategies, whenever they deem it convenient.
7. The collaboration between the PCT and the corresponding CFCU is key for the difficult management of complications, co-morbidities and advanced phases that chronic patients end up suffering and for the adjustment of individualized treatment plans to each circumstance.
8. The transitions of the hospital discharge of patients must be planned early and in a personalized way by a cross-disciplinary multidisciplinary team and, once the patients arrive home, they must receive a structured and coordinated follow-up between the PCT and the CFCU.

I don’t have data, but I believe that with this KP inspiration plan, many patients would be included and many comings and goings between healthcare levels would be reduced, as well as little value and even unnecessary use of resources. Putting order and common sense to the flow generated by patients affected by the most frequent chronic diseases can bring many benefits to people and service provision systems.

The time has finally come to see innovation as an investment. Do not doubt it, a decided commitment to collaborative transversal functional units between primary care and hospitals is a key strategy to make the much-touted integration of services a reality.