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.

"Carried me with you": the objectives of integrated care are a matter of more than one

Mònica Almiñana
 

This song from the Onward soundtrack, one of Disney's latest animated productions, bring about a good mood because, in addition to having a country touch, I have always liked lyrics that speak of how important it's that they accompany you, guide you and help you achieve your goals.

Care for chronic patients during the pandemic. 5 proposals from hospitals

Nacho Vallejo

Image by Parentingupstream from Pixabay

Faced with the difficulties of a third wave of the pandemic, clinicians again need to express their concerns. And not only because of the exponential increase in the number of COVID-19 patients but also because of the feeling of once again leaving behind the care of patients with chronic health problems. It’s a situation sadly favoured by the collapse of primary care and hospitals.

Caring for complex patients in the community requires a radical change

Jordi Varela

Editor

The pandemic has highlighted the need to protect, even more, if possible, people suffering from clinical complexities and some of them, in addition, family, economic or social difficulties. For this reason, some primary care centres have set up nursing teams to more proactively care for the most vulnerable patients. These groups of nurses have taken the initiative and now organize their tasks, most of them at home, in an autonomous way, according to a fine balance between coordination and effectiveness. The historical medical-nurse binomial of primary care, then, is beginning to show cracks that give way to advanced organizational models with more nursing skills.

Do we really want to change things? About Kotter’s 8 steps

Jordi Varela
Editor

 

Our iceberg is Melting is a fable that illustrates very well that detecting problems is not the same as wanting to fix them. Fred, an observant penguin, realizes that his iceberg is cracking, a matter that will be catastrophic for the entire colony living obliviously to the problem. The author, John Kotter uses the fable to unravel the 8 steps that any individual, in Fred's circumstances, should follow if they want to save the penguin colony:

Hospital outpatient department, the great mess

Jordi Varela
Editor

 

Hospital day services don’t stop growing to the detriment of traditional hospitalizations, to the extent that the NHS has estimated that, in England, patient movements to hospitals generate 5% of road traffic throughout the country. Many of these services, such as surgery without admission, chemotherapy, anticoagulants or endoscopies, have been very well outlined since their origin, external consultations in general, on the other hand, are multipurpose devices where each speciality has accumulated outpatient services of very different characteristics until they become overflowing spaces that are difficult to manage, precisely because they have not defined what is expected of each of their activities. To give an example, a rheumatologist told me that it was unfortunate that they were evaluated due to the relationship between first and subsequent visits, when it’s known that his patients are complex forever, and he suggested that it would be convenient to be able to assess their service based on the quality of life their patients get, about the costs of prescribed treatments.

The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Hospital emergencies: the refugee camp of the healthcare system

@varelalaf

The society witnesses the emergence of population groups with social and health care needs that are difficult to fit in the current model of service offer. Thus, we see how fragile and vulnerable people are picked up by ambulances and go to hospital emergency rooms, which become like refugee camps, as Sara Kreindler, head of health systems innovation research at the University of Manitoba (Canada), likes to call them. Many initiatives, observed everywhere, aim to put an order in these refugee camps of healthcare: implantation of triage, observation units, geriatric units, new case management nurses, nurses trained in geriatric evaluation. To help us analyze a problem that we don’t know how to address, Sara Kreindler has developed a qualitative study in the framework of a region of Canada. The study has concluded that partial interventions aiming to improve the flow of urgent care for patient’s complex show three paradoxes:

The individualistic short-sightedness of health care

The Global Action Plan for the prevention and control of non-communicable diseases of the WHO aims to reduce by 25% the premature mortality due to these pathologies by the year 2025 (strategy 25 x 25) and, therefore, concentrates on strategies that reduce the following 7 risk factors: a) alcohol consumption, b) insufficient physical activity, c) tobacco consumption, d) high blood pressure, e) excessive salt intake, f) diabetes, and g) obesity. Confronted by this individualistic drift of public health, an international group of researchers has published in the Lancet the results of a meta-analysis with 48 cohort studies and 1.7 million individual records, where they have shown that poverty has more explanatory force by itself over the number of years of life lost that many of the factors 25 x 25, in addition to having an undeniable cross-influence by enhancing the aforementioned risk factors. It’s important to clarify that the cohorts selected by the researchers correspond to first world countries, so the analyzed groups of low socio-economic level  represent poverty pockets that are basically concentrated in deprived neighbourhoods of large cities or in certain collectives such as the destitute or the immigrants.

Cumulative complexity and minimally disruptive medicine

The clinical model based exclusively on the diagnosis and treatment of chronic diseases is precipitating medicine to fail. Addressing complex realities from partial positions is, at least, unfortunate, and despite this evidence, health care systems continue to finance the fragmented provision of services. Mary Tinetti and Terri Fried warned us in 2004, in "The end of the disease era", that it should evolve towards a bio-psycho-social model, prioritizing the integral evaluation of each person, adjusting the therapeutic plans to each reality and offering integrated services. The analysis was timely except that the authors were wrong when they predicted that, the old model would end with the advent of the new century.

ICUs and the elderly

There is concern about the misuse of hospital resources by the elderly, assuming that in many circums-tances, the services received, apart from being disproportionate, may also be more harmful than beneficial. The last post analysed the syndrome of post-hospitalization, a pathology that contracted the vulnerable people by the fact of them having been admitted to a hospital. In the same vein, I would like to comment on a clinical trial carried out in 24 French hospitals, with more than 3,000 people over 75 years of age in a clinically critical situation, of which half entered a program that promoted ICU admission , while the other half simply followed the standard criteria of each centre, without any external pressure. In the observed results, the patients in the intervention group logically entered the critical units (61% versus 34%), but this did not lead them to live longer, since, despite the fact that the gross mortality at 6 months was higher in the group that had observed greater use of ICUs (45% versus 39%), after adjusting the numbers*, relative risk was reduced to 1.05 (not significant).

The post-hospitalization syndrome

Harlan Krumholz (Yale) is a cardiologist who focuses his research on the impact of health services on health outcomes (Center for Outcomes Research and Evaluation - CORE), and on "Post-Hospital Syndrome. An Acquired, Transient Condition of Generalized Risk" focused its attention on readmissions, a problem that affects 20% of people who are discharged in the US. In this context, Krumholz's most prominent finding in the article was that of Jenks and colleagues (with 12 million Medicare discharge records), which enabled them to conclude that patients who had been admitted with decompensations of the most common chronic pathologies: heart failure, pneumonia, COPD or gastrointestinal disorders, if they were readmitted before 30 days, they did so in two-thirds of the time, for reasons other than the diagnosis of the previous admission.

Focusing on the daily life of frail people

The PACE (Program for All-Inclusive Care for the Elderly) model was born in 1971 when a dentist and a social worker working for the San Francisco Department of Public Health in Chinatown-North Beach realized that older people were reluctant to move to a social residence when, instead, with some complementary services, they could continue to live in their own homes, in a more friendly and stimulating environment. Nearly fifty years later, PACE enjoys good health and "The Commonwealth Fund" has published a "Case Study" analysing its operation and results.

On the subject of continuity of care in hospitals

Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

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.

Self-management: Buurtzorg Identity

Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

The myth of lack of adherence

Cristina Roure

It's not that they don’t know or don’t want to know, it's that they can’t

I recently read of a doctor complaining that when he began his career, he assumed that if a disease was treated, the patient would improve, but in reality the results were far from expectation. It isn’t surprising if we remember that adherence to advice and treatment in chronic patients is less than 50%, as shown by a recent survey conducted in Spain in a sample of 1,400 chronic patients.

Despite attempts to change the attitude and pardon the patient, such as calling those that don’t comply or adhere, the truth is that systems to increase adherence to treatment always focus on changing patients’ attitudes or aptitudes. Lack of adhesion is rarely viewed as a system problem.

Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

An extensive model for complex chronic patients

The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

What do chronic patients want?

Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.