We have worked a great deal with the idea of “promises” - a set of conditions that a health care provider should be able to promise to a patient who faces a fatal illness. These are spelled out on ABCD’s website; in brief, the patient should be able to count on having the correct treatments, no overwhelming symptoms, no gaps in care, advance plans so that there are no surprises, opportunities to customize care, family situation taken into account, and help to make every day as good as possible.
How would a care system need to be organized to make promise-keeping possible? While many people are tackling this in many different ways, they share some common elements. First, some “entity” has to “take ownership” of the problems for a population - not just an institution. One cannot reliably improve end of life care only by working within a hospice, or a hospital, or a home care agency. Many parts of the care system are so interdependent that coordinating patient care across programs is essential. The opportunities for error - and for improvement - are plentiful.
Imagine a patient who is transferred from a hospital that prefers morphine pumps to a nursing home that prefers fentanyl patches, in an ambulance whose crew does not like handling controlled substances at all - what are the odds that the patient will get the right treatment throughout? Not good. Indeed, the odds can go against good care with transfers from one service or physician to another. We must consider the care system from our patients’ perspective – as a whole. In most cases, however, no group or administrative structure claims responsibility for performance of the whole.
Some interesting entities are being to emerge. Sometimes a regional consortium that arose in part to apply for the Robert Wood Johnson Foundation Community-State Partnerships covers a small enough and cohesive enough geography to take this issue on. In Vermont, various private groups and the state public health agency are taking steps to encourage each county’s hospital, nursing home(s), home care, and hospice to work together on mission, guidelines and advance care planning. Colorado has some of the same ideas coming forward in a new funding initiative. Sometimes, a large care system actually does “own” all the pieces – and some of them are gradually recognizing their opportunity for excellence in having their long-term care, hospice, and acute care entities make care coherent.
Next month: Part II - Reorganizing Care
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