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Finding the Right Place for Care

Collaboration between hospitals and drugstore chains can improve care by helping to fill gaps in the continuum

If any philosophy could capture what success looks like in both patient care and the efficiency needed to alter the steepening slope of healthcare cost increases, it's a saying many in healthcare have adopted: Right care, right place, right time.

It's trite, but it's also accurate and succinct. That phrase, often cited by wonks, policymakers, hospital and health system leaders, employers, and commercial health plan leaders, is the key to many of the challenges that plague healthcare, such as uneven quality, overutilization, and high variation and cost. The difficulty, as always, is in the execution, because providing the right care in the right place at the right time requires coordination of a vast array of complex moving parts, not to mention the cooperation of the patient.



Meeting the Challenge of Patient Engagement

Healthcare systems are using high-tech and high-touch approaches to reach patients where they are and with what they need, but an actively engaged patient remains an elusive partner in care.

Providing a patient with clinical care that is safe, effective, and costs less all are high-priority issues competing for the attention of leadership at hospitals, health systems, and physician groups. Top organizations are developing new models of care with the patient at the center of this new paradigm, but it is the patient who is a key variable that can sink a system's efforts.

In the April 2014 HealthLeaders Media Intelligence Report, The New Primary Care Model: A Patient-Centered Approach to Care Coordination, 59% of respondents cited patient engagement as one of the most challenging clinical components of primary care redesign. But it can be argued that patient engagement is a sticking point no matter the setting.

At face value, the term patient engagement seems straightforward. For example, patients who come in for their annual wellness exams on time, or patients with a chronic disease like diabetes who are faithfully taking their medication, monitoring their blood sugar, and coming in for regular checkups would be considered engaged patients.



Most Hospital Palliative Care Programs Are Understaffed

An analysis of palliative care programs found that only 25 percent funded teams that included a physician, an advanced practice or registered nurse, a social worker and a chaplain, the four positions that are recommended by The Joint Commission

Most hospitals offer palliative care services that help people with serious illnesses manage their pain and other symptoms and make decisions about their treatment, while providing emotional support and assistance in navigating the health system. But hospital programs vary widely, and the majority fail to provide adequate staff to meet national guidelines, a recent study found.

A growing body of research has shown that palliative care can improve the quality of life for patients with serious illnesses and complex, long-term needs. In one study, patients with advanced cancer who had discussions with their doctor about their wishes were less likely to die in the intensive care unit, be put on a ventilator or have cardiopulmonary resuscitation, for example.

Although many people, including medical professionals, continue to associate palliative care only with end-of-life care, it is appropriate for many people in many settings who are living with debilitating long-term illnesses.

In 2013, two-thirds of hospitals with at least 50 beds reported having a palliative care program. At hospitals with 300 beds or more, the figure was 90 percent, according to a study published in the Journal of Palliative Medicine earlier this year.

But not all programs provide the same level of service. In the September issue of Health Affairs, an analysis of 410 palliative care programs found that only 25 percent funded teams in 2013 that included a physician, an advanced practice or registered nurse, a social worker and a chaplain, the four positions that are recommended by the Joint Commission, which sets hospital standards, including those for accreditation. If "unfunded" staffers were counted, those who were on loan from other units, for example, the figure rose to 39 percent.

Study coauthor Diane Meier, a professor of geriatrics and palliative medicine at the School of Medicine at Mount Sinai in New York and director of the Center to Advance Palliative Care, said she wasn't surprised by the low numbers.

"There are no regulatory or accreditation requirements that enforce the staffing guidelines," Meier said. Although the Joint Commission recommends a staffing standard, hospitals aren't currently required to have palliative care teams in order to be accredited, Meier said.

"The hope is to shine a light on the gap in what everyone agrees is the [staffing] standard. If we're invested in improving the quality of care, this is what it will take."