How fragmented and silo structures affect health care delivery to vulnerable populations?

Due 10/22/2020 5pm, see attached example Question: How fragmented and silo structures affect health care delivery to vulnerable populations? Describe emerging and tested ideas for better health delivery. Feel free to mention ideas presented in the textbook as well as any of your own.

Knickman, J.R., & Elbel, B. (2019). Jonas and Kovner’s health care delivery in the united states (12th ed.). Springer Publishing Company.

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Question: How fragmented and silo structures affect health care delivery to vulnerable populations? Describe emerging and tested ideas for better health delivery. Feel free to mention ideas presented in the textbook as well as any of your own.
Defined by Stange (2009), a fragmentation of health care delivery is one that is focused on parts of health care delivery instead of the whole picture, and one that is unbalanced, broken. It is a root cause of an unsustainable increase in cost, poor quality, and inequality in the healthcare system. Vulnerable population already have existing problems in their lives, such as low income, poverty, inadequate resources, limited education, and these barriers compile with the fragmented health care structures to create a roadblock in accessing proper health care services that are equal and efficient.
A perfect example of how fragmented the U.S. health care system is seen in the volume versus value notion, providers are encouraged to be volume-driven, instead of value-driven. For instance, the fee-for-service (FFS) has been encouraging providers to earn more revenue by taking more patients in their appointment list (Knickman & Elbel, 2019). The more patients seen, the more revenue to the individual provider, which also means less quality time spent with each patient to provide a holistic service of care. It is a problem for especially the vulnerable population, as there are so many areas where they need assistance from the provider. For example, if a patient with mental health illness and other chronic diseases comes to the primary care clinic just to refill their regular medications, a provider who is focused on volume-based service will only focus on the prescription due to limited visit time. A value-based provider on the contrary would focus the quality of care by providing an in-depth assessment of what else the patient needs. Does the patient need mental health counseling or referral? Does the patient need annual physicals, screening, and preventive measures? These important aspects of care would be address in an ideal health care delivery system.
Another fragmentary aspect of the health care delivery system in this country is that patient care is not coordinated. There is no communication between different providers that are involved in the patient’s care, whether it be the cardiologist, primary care doctor, or podiatry (Knickman & Elbel, 2019). Many of these vulnerable population, who perhaps have limited literacy or resources, don’t know much about their health. They might not know what specific medications, their doses are, and when they last had their screening done. When providers are not proactive in communication with other providers, the fragmentation causes unnecessary or repeat orders of tests, and medications. So, patients end up paying more, run around in a maze, and have less quality of care. Henceforth, one systematically fragmented health care delivery system leads to inefficiency, ineffectiveness, inequality, commoditization, commercialization, and deprofessionalization, and a despair health care delivery system (Stange., 2009).
So, what are the solutions to this fragmented health care delivery system? There are several strategies that can help meet the goals of the vulnerable population and reduce a fragmented system. Knickman and Elbel (2019) stated that health care has to be based on care coordination, where different services and providers caring for the patient need to coordinate activities of patient care so that things like duplicate test and medication orders are prevented. Moreover, care provided to vulnerable population really has to be patient-centered and team-focused. This means putting patient at the center of coordination of care and involving different people, such as social workers, providers, nurses, case manager, and other specialty health care personnel in the table so that everyone is in the same page and can provide effective and efficient resources for that vulnerable patient. Additionally, Joshi et al. (2017) described the importance of electronic health record (EHR) in providing effective population health surveillance. This is especially important for vulnerable population requiring multiple health care services. Patient information should be available in big data format thru EHR so that providers know all aspect of patient’s health care and facilitate future care.
To end, I want to provide a real-life example of how fragmented the health care delivery system is in this country. About 6 years ago when I was working at the Kings County Hospital, I took care of a patient with an interesting story that reminds of how fragmented our health care system looks like. The patient was a male in his 40’s. He was found at his home in the floor with bug infestation, malnourished, and was brought in the ED with systolic BP in the 60’s. His mother dropped him off in the ED and then never showed up. He required mechanical ventilation and then later had tracheostomy. The patient did not have any legal documentations and no family members came in contact, even the mother who left him in the ED. So, the patient become the city hospital’s responsibility. He was in the hospital in the unit I worked for 2.5 years, developed pressure injuries and many other complications; while the hospital was battling to figure out what to do. He was not qualified to go to a nursing home with trach without legal documentation. It required years of court processes to get him a legal guardianship before he was discharged. The moral of the story is that he was a vulnerable patient who didn’t have any family member to advocate for his needs. There was no significant medical record at admission because the EHR in this country serves separately, instead of collaborating to share valuable patient information. A significant issue with his case was inadequate care coordination between case management, providers, and other individuals in the health care system, which delayed everything. The sum of the problem here were an increased cost to the hospital due to 2.5 years of hospitalization, and ineffective care where patient developed more injuries staying at the hospital than he otherwise would have elsewhere. The story begs the questions of what can we do to change this? There are many solutions. One solution I propose is a universal health care system with universal electronic health record system that patients and providers can have access to, where information is kept in one place instead of several different systems. Lastly, there also needs to be more care coordination, and team-based approach to caring for the vulnerable population if we want to prevent a fragmented health care delivery system.

References:
Joshi, A., Thorpe., & Waldron, L. (2017). Population Health Informatics. Jones & Bartlett Learning.
Knickman, J.R., & Elbel, B. (2019). Jonas and Kovner’s health care delivery in the united states (12th ed.). Springer Publishing Company.
Stange, K. C. (2009). The problem of fragmentation and the need for integrative solutions. Annals of Family Medicine, 7(2), 100-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653966/

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