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Community Connections for Health Care - Part IV of IV

by Joan Bachman

COORDINATION OF CARE AND SERVICES FOR THE CLIENT                                       

The single most important element of the Health Care System is the client. Because of configuration of the System, particularly the reimbursement segment, the client may feel left out of the equation when it comes to making informed decisions to fit personal wishes. This situation seems to also decrease the client’s acceptance of personal responsibility for health status and treatment options.  Too often, health care and services are ‘done to’ the client.

Previous topics of this Blog set have described the provider types, functions of the provider types, and reimbursement for health care and services. The trick is to make use of this information for appropriate coordination for each individual who has need for health care and services. A client may not be aware of all the provider types, may have incomplete understanding of the functions and reimbursement of the provider types, and so be unable to make good choices to reach the desired health outcome. Coordination of services between the confusing array of resources is an important function of every provider for every client at every encounter.  The task is often difficult and time-consuming. Because of the time involved, providers may not complete a coordinated referral for a client.

The coordination piece is called the HAND-OFF or DISCHARGE PLANNING.  This handoff or discharge planning is the connection that is necessary to put the many pieces of health related services together to actually benefit the client. Because the system is so complex and many providers fail to take the time to listen and share complete information with the client, it is difficult for the client to ask informed questions for help through the next steps to the best health status possible.

As a health care or service provider, each of us has a responsibility to understand as much as possible about each client; about how he views himself and his world, and his hopes for the future. To gain this understanding, the provider must listen and observe, and document the information to be shared with other caregivers as appropriate.  Elements to be considered during the client stay or visit include physical abilities (ambulation, sight, hearing), mental/emotional status, chronic disease, financial status, language/cultural belief system, personal environment (family support, living arrangements), access to resources (food, prescriptions, assistive devices), geography (urban/rural – transportation, follow-up), and education.  When preparing to release the client or refer him to another step in the system, it is important to be certain that you and the client agree on the desired outcome and that the client understands what is involved in each of the next steps. 

A successful Hand-Off is defined as a transfer and acceptance of responsibility for client services and care between providers that is achieved through effective communication.  A properly executed "Handoff" or “Discharge” between health care providers will prevent errors, improve quality, save time and money, and ensure a healthier client.

Examples of good handoffs: 1. A medication prescription ordered by the clinic physician is called to the pharmacy as promised and method of delivery to the client is clear, assured, and completed; 2. After-hospitalization care instructions given by the hospital staff person to the discharged patient and family, ensuring the patient understands limitations and has access to necessary medications, supplies, and assistance at home; 3. The assisted living facility sends copies of relevant documents and information with the resident who is making a visit to the physician’s office. 

Ideally, the many providers in a local health care system will establish working relationships and systems of regular communication. In a rural community, we established a useful working relationship between the local hospital/nursing facility, free-standing nursing facility, County Social Services, and County Public Health to work together to find best services for clients we were each serving in some manner. We arranged for meals on wheels to help someone remain at home, found resources to minimize the charges for delivery of the baby of an unwed mother, and provided chronic care training to eliminate frequent re-hospitalizations. The concentration of our relationship was on client success.

Coordination requires the transfer of correct information to support the client in moving toward wellness and well-being. This implies there should be a mechanism for tracking how the patient responds to the coordination between care providers. Such a mechanism requires compatible documentation systems and trust between providers. The system is not well-designed to accomplish this evaluation, so acknowledgment of client reporting is important.

Successful care coordination will lead to less waste in expenditures caused by duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from one provider to the next. Clients and the health care system would experience fewer problems with smooth coordination.  News channels have reported that a recent Johns Hopkins Study found that the 3rd leading cause of death in the United States is medical errors.  Improvements in handoffs both within the organization and between organizations would decrease this shocking number substantially.  The information you pass on regarding your client may save his life. 

Websites are listed here that may provide useful ideas to assist you to execute successful handoffs. The mechanics of the handoff or discharge planning are adaptable to every instance of health care and service for every client.

http://www.ncbi.nlm.nih.gov/books/NBK2649/

http://jama.jamanetwork.com/article.aspx?articleid=1558280

http://medicine.osu.edu/hrs/research/Documents/02-patterson.pdf

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