Patients in Ontario are increasingly being treated by multiple caregivers, providers and stakeholders. Now more than ever, it is essential to have care coordination between all these groups to ensure the best health outcomes for the patient.
When a hospital, primary care physician, long-term care home, community organizations and others work in a coordinated fashion, the patient becomes the centre of care and benefits from an integrated care model, one that sees a care plan for each patient.
This community-focused health model has been an aim for years around the world, and it makes sense, both economically and from a health perspective – especially in regard to chronic disease, mental health, substance abuse and addiction and end-of-life issues.
As a primary care physician, I believe that coordinated care can do much to help by leading a community-based effort to improve care for the patient. Continuity of care is only possible with integration of information across the community and with the use of an integrated care plan linking the efforts of all care providers involved with patient. This must include the patient.
Today in Ontario and beyond the confines of its hospitals, patient information is often fragmented and siloed. Clinicians often lack the means to share and access complete information with other clinicians when they provide care and care planning for their patients. This often leaves a patient having to answer similar questions raised by multiple clinicians, and unnecessarily repeat procedures, while increasing the potential for medication errors. Integration and sharing of patient information is fundamental for coordinated care.
For care to be coordinated, it needs to be wrapped around the patient. Improved care coordination has been shown to have positive impacts across the system. Evidence shows that, in addition to technology, face-to-face and home visits significantly improve outcomes for these patients. Furthermore, hospital readmission rates are reduced in a range of environments and settings.
Another highly relevant area for care coordination is planning for the end-of-life. In a recent webinar, Dr. Jocelyn Charles, who has been appointed to physician adviser, primary care strategy, with the Toronto Central Local Health Integration Network, discussed how a fully integrated model of care coordination changes the way health-care providers interact with patients, colleagues and families during the trying end-of-life time.
She described a case of an elderly patient’s last days: “He was high functioning, but living alone with several co-morbidities and declining health. The patient understood that he might pass away soon but did not share his final wishes with his family members as he found the subject difficult to broach.”
The patient wished to die at home, and not in an acute hospital intensive care unit. Dr. Charles was able to capture the patient’s wishes in the care coordination plan. The patient later suffered a stroke and was unable to provide direction, but since his preferences were registered in his care coordination plan, he was taken home, where he passed away peacefully. The family was very pleased that his wishes for terminal care were known and followed.
Care coordination is not a new idea. Community nurses, for instance, have promoted the evolution of care coordination for many years. We now have an opportunity to go beyond simple case management to create integrated, coordinated care plans that include both clinical and patient descriptions of ongoing issues, next steps to be taken, perceived patient risks and contact information for all stakeholders.
Dr. Chris Hobson is a family physician with 15 years of experience and is the chief medical officer at Orion Health, a health-care information technology company founded in New Zealand.