Monday, October 22, 2007

Patient-Centered Life-Cycle Value Chain: the Sick Care link

In my previous post, I discussed the first link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is emergency care through emergency management. In this post, I discuss the second link, which involves sick-care, also known as the “clinical encounter” between a patient and one or more healthcare providers.

Sick-care consists of the following six categories of physical and psychological problems (including diseases, illnesses, dysfunctions, and traumas):

  1. Acute health problems characterized by sudden onset and short duration, which progresses rapidly and require urgent care. An acute myocardial infarction (heart attack) and serious accident victim are examples.
  2. Subacute health problem distinguished by abrupt onset, but it has longer duration or changes less rapidly than acute problems. Examples include post-operative care, complex wound management, and rehabilitation for stroke.
  3. Chronic health problem of indefinite duration, which may persists with virtually no change over time, or which may lead to complications. Diabetes, depression, congestive heart failure, hepatitis and asthma are examples. Note that once stabilized, enabling patients to adhere to plans of care for avoid complications and premature death is part of well-care.
  4. Physiological health problems consist of illnesses and dysfunctions in any part of the body.
  5. Psychological health problems consist of emotional, mental, or behavioral disturbances and disorders.
  6. Mind-Body (Biopsychosocial) health problems are related to the interaction between physiological and psychological factors.
Sick-care has five sick-care delivery models for delivering tests and procedures (treatments):

  1. Inpatient Care model focuses on treating patients in hospitals, nursing homes, and other inpatient facilities.
  2. Outpatient Care model focuses on treating patients in the offices of primary care physicians and specialists, clinics, and other outpatient facilities.
  3. Medical/Bodily Care model focuses on delivery of (a) emergency medical care (e.g., accident victims, infections, poisoning, etc.) and (b) non-emergency medical and non-medical bodily care (e.g., elective surgery, chiropractic, dental, vision, etc.).
  4. Psychological Care model focuses on delivery of medical/psychiatric and non-medical/psychological care for mental, emotional, cognitive, and behavioral problems.
  5. Biopsychosocial/Integrative Care model focuses on delivery of integrative (mind-body) care for problems having physiological and psychological causes or consequences.

Sick-care delivery processes focus on diagnosing and treating health problems in inpatient and outpatient sick-care settings:

  1. Inpatient care processes for physical and psychological health problems including (a) emergency room/trauma center care; (b) obstetrics; (c) tests and examinations; (d) elective surgery; and (e) psychiatric care for severely disturbed patients.
  2. Outpatient care processes physical and psychological health problems including (a) tests and treatments for physical and psychological problems during primary care during office visits to primary care physicians and specialists, as well as to ambulatory clinics and other such facilities, and (b) coordinating care for patients requiring multidisciplinary teams can work together effectively.

A core problem with sick-care today is that we rarely know what constitutes cost-effective (high-value) sick-care that is tailored to a patient's particular needs and characteristics. That is, we lack patient-specific evidence-based guidelines about how to treat each patient so they get well rapidly and with least risk and complications. This is because our country hasn't focused on supporting the kinds of research and information systems necessary for generating and using the knowledge (best practices) providers and patients need for improving treatment outcomes/results and controlling costs.

On top of that, high-value sick-care is less profitable than wasteful, inefficient, redundant, excessively costly and error-prone care. This is because our crazy payment system rewards high volume and costly procedures through higher profits, while it discourages the efficient delivery of cost-effective care through lower profits.

In the PCLC Value Chain, therefore, sick-care focuses on:

  • Using and evolving evidence-based practice guidelines defining how to deliver cost-effective care
  • Assessing and improving clinical outcomes continuously
  • Empowering healthcare consumers to make knowledgeable decisions about their own care by being active participants in shared decision-making
  • Treating the “whole person,” both physically and psychologically
  • Tailoring care to each person’s specific needs and preferences
  • Coordinating care and facilitating cooperative communications across all providers treating a patient for better continuity of care
  • Fostering collaboration between practitioners and researchers
  • Maximizing safety and efficiency
  • Utilizing advanced information systems for supporting diagnostic and treatment decisions
  • Assuring greater financial gains to providers dedicated to delivering high-value care.
In my next post, I examine the third link in the PCLC Value Chain: Well-Care.

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