Description
The coordination and continuity of care are two closely related and important aspects of quality of care. Coordination implies the connections that occur between the people and the institutions that provide health care at a point in time or over a short period of time usually focused on an episode of illness. Continuity deals with relationships over time perhaps years or decade. Please refer to table 10-2 to review the types of coordination of care and challenges presented.After reading the case study Jack and Continuity of Care, please answer the following questions:1) How does this case illustrate the lack of institutional continuity?2) How does this case illustrate the lack of financial continuity?3) What role does social work play in this case? Where could a social worker have intervened? What interventions could they have used?
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4/14/2020
Public Health 101: Improving Community Health, Third Edition
Advantage Access for Public Health 101, Third Edition (Open Enrollment)
ISBN 9781284134735
SECTION IV Cases and Discussion Questions
Jack and Continuity of Care
▶ Jack and Continuity of Care
Jack was told that he had high blood pressure and high cholesterol when he was in
the army. Because the conditions did not bother him, Jack paid little attention to
them. His job did not provide health insurance, so he decided to take his chances
rather than spend his last dollar paying for insurance through an exchange. Anyway,
he was strong and athletic. Over the years, Jack gained weight, exercised less, and
developed a “touch of diabetes.”
When the diabetes produced symptoms, he went to the emergency room, where
they did a good job of diagnosing his problem and sent him off with a prescription
and a few pills to get started. The pills seemed to help, but Jack could not afford to
fill the prescription or follow up with his “family doctor” because he did not have
one. Jack did not understand all the terms the doctors and nurses used to describe
his condition, but he knew it was serious and could get worse.
It was not long before he was sick again, so this time, he sought care at a community
health center. He did not qualify for Medicaid, but the treatment was affordable. For
a couple of months, he followed up and was feeling better, but on the next
scheduled visit, they told him, “You need to be in the hospital—you are getting
worse.” They got him to the hospital, where he was admitted to the university
service and assigned to a young resident who had just graduated from a well-known
medical school. The resident reviewed his condition, developed a treatment plan,
and explained to Jack what needed to be done. He ordered a tuberculosis (TB) skin
test and collected sputum to check for TB because of Jack’s chronic cough.
Unfortunately, before the treatment could be implemented, the resident rotated to
another service and Jack’s new resident did not seem to pay much attention to him.
Jack decided to leave the hospital against medical advice and left no forwarding
address. His TB skin test was never read. When his positive sputum culture for TB
came back, the laboratory alerted the local health department. Not knowing where
Jack lived, the health department was not able to follow up.
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Before he left, the hospital made sure that Jack had signed all the forms to receive
Medicaid payments for the hospitalization. However, Jack did not complete the
forms because he did not plan to get any more medical care. That changed one day
when the pain was more than he could stand. He decided to try another emergency
room. This time, the place was very crowded, and he had to wait hours to be seen.
Once he was examined, the physicians and nurses tried to get information from him
on his condition and treatment, but Jack could not provide much useful information.
He was prescribed pain medicine and sent home. He was told to follow up with a
doctor in the next few days. By then, it was too late. One morning, as he was getting
up, Jack’s left leg was weak and numb and he lost his speech. He struggled to call
911. Despite the fact that he could not speak, the operator was able to send an
ambulance by tracing his telephone location. The EMTs rushed to Jack’s home and
got him to the nearest hospital. Once again, the emergency room clinicians
evaluated him, but this time, it was too late to be of much help. Jack was admitted
for a stroke.
He stayed in the hospital for a week and made some improvement, but he needed
help with the activities of daily living and could only speak a few words. The hospital
was able to place him in a rehabilitation center because Jack, now 65, qualified for
skilled nursing care under Medicare. He was transferred to the facility and received
intensive rehabilitation services for the next month, until he no longer improved. At
that point, Jack was no longer eligible for skilled nursing care. He was transferred to
a Medicaid nursing home closer to his only relatives. The new facility had a large
number of patients needing “custodial care.” It provided all the services required by
law, but Jack soon realized that he was just another stroke patient.
Discussion Questions
How does this case illustrate the lack of institutional continuity?
How does this case illustrate the lack of continuity between the healthcare and
public health systems?
How does this case illustrate the lack of financial continuity?
What role does the lack of information play in this case? How can information
technology serve to reduce or eliminate these lapses in continuity?
Which lapses in continuity require other types of interventions?
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Public Health 101: Improving Community Health, Third Edition
Advantage Access for Public Health 101, Third Edition (Open Enrollment)
ISBN 9781284134735
Chapter 10 Healthcare Institutions
What Types of Coordination of Care Are Needed and What Purposes Do They Serve?
▶ What Types of Coordination of Care Are
Needed and What Purposes Do They Serve?
As we have discussed, the traditional approach to coordination of care revolved
around the clinician–patient or doctor–patient relationship. Traditionally, the
concepts of continuity of care and coordination of care have been almost
synonymous. This approach assumed that the relationship between one doctor and
one patient would provide the individualized knowledge, trust, and commitment
that would ensure the coordination of care by ensuring the continuity of care. The
concepts of primary care that we have discussed were built in large part upon this
concept of one-to-one continuity.
Today, there is an increasing emphasis on ensuring coordination rather than one-toone continuity. Coordination is sought between institutions and settings where care
is delivered. The approach that leaves continuity of information and continuity of
responsibility for care to individual clinicians alone has often failed to produce the
desired results. As we will see, efforts are underway to formally link institutions,
services, and information between the various healthcare delivery sites and
institutions.
Institutional coordination often relies on financial coordination. If services are
covered by insurance in one setting but not another, the system is not likely to
function efficiently or effectively. When services are not covered at all, patients may
receive excellent care in one setting only to lose the benefits of that care when
necessary preparation or follow-up is not paid for and not accomplished in another
setting.
Coordination is not just an issue within the healthcare delivery system; it is also an
issue that straddles healthcare delivery and public health functions. Communicable
disease control and environmental protections, such as controlling antibiotic
resistance and lead exposure, cannot be successful without effective and efficient
coordination between healthcare and public health professionals and institutions.
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TABLE 10.2 outlines these types of coordination, their intended function, and the
types of challenges that commonly occur with their implementation.
TABLE 10.2 Type of Coordination of Care, Intended Functions, and Challenges
with Implementation
Type of
coordination
Intended function
Challenges with implementation
Clinician–
Continuity as a mechanism for
Multiple clinicians involved in care
patient
ensuring coordination
relationship
Team rather than individual concept of
Development of one-to-one
primary care
relationships built on knowledge
and trust over extended periods of
Frequent changes in insurance coverage
time
require change in health professionals
Institutional
Coordination of individual’s
Different structures and governance often
coordination
information between institutions
lead to lack of coordination between
needed to inform individual clinical
inpatient facilities and between inpatient and
and administrative decision making
outpatient facilities
Financial
Implies that a patient has
Lack of comprehensive insurance coverage
coordination
comprehensive coverage for
often means that essential services cannot
services provided by the full range
be delivered or cannot be delivered at the
of institutions
most efficient or effective institutional site
Aims to maximize the efficiency of
the care received and minimize the
administrative effort required to
manage the payment system
Coordination
Coordination of services between
Lack of coordination of services between
between
clinical care and public heath
public health services and clinical care is
health care
requires communication to ensure
often based on lack of communications
and public
follow-up and to protect the health
health
of others
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Let us take a look at the development of healthcare delivery systems as one
approach to ensuring coordination of health care.
TED Talks: Atul Gawande: How Do We Heal Medicine?
THIS WIDGET IS REFERRING TO URL ‘https://youtu.be/L3QkaS249Bc’. PLEASE GO TO EBOOK VERSION TO
LAUNCH THE LINK.
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