A Pound of Primary Health Care

Health care. Very few phrases envelope so many different aspects of an area of discipline. It can be confusing to know where to go to and when, and this issue has led to a cascade of health problems for our population and our population’s health care system. Emergency room or primary care? And where does preventative care fit in? Here’s an overview of a few facets of the system, and how they differ from each other.

Why Not Just Visit Emergency?

Most emergency departments offer a wide range of services available at all hours, without the requirement of an appointment. However, many ER visits are avoidable as patients are seeking non-urgent care or care that could have been treated and even prevented by primary health care. These avoidable visits result in higher costs, longer emergency department waits, and fewer resources available to the patients who actually require emergency services. Interestingly enough, misuse of the emergency department is equally committed across all ages, regardless of whether or not they are insured. This population-spanning issue has even spurred an “Urgency or Emergency” ad campaign in New Mexico coordinated by the Albuquerque Coalition for Healthcare Quality and funded by the Robert Wood Johnson Foundation.

It is essential to provide and spread education about appropriate times to facilitate emergency services, walk-in to an urgent care clinic, or wait to make an appointment with your general practitioner.

So when do you visit the emergency room?

Examples are incidences of:

– Difficulty breathing

– Uncontrolled bleeding

– Loss of consciousness

– Severe burns

– Chest pains

– Broken bones

When do you visit urgent care?

Any time that you experience a change in your health status which needs attention, but will not be an immediate threat to your health.

Examples of these incidents are:

– Migraines

– Back pain

– Earaches

– Sprains

– Rising fever

– Minor lacerations

Primary Health Care / Primary Care: The Same But Not!

Primary health care is an extensive and broad model designed to cater not only to the individual and their family but to their community as well. Primary health care is meant to be an accessible community based system, responding to the to social issues of the population it is serving.

Primary health care works to:

– Prevent illness and be promotive of health (as opposed to working solely in a curative manner as seen in primary care)

– Focus on maximizing individual and community involvement in the planning and operation of services as well as in the integration of health development with social and economic development

– Integrate rehabilitative and therapeutic care into patient’s daily lives

The presence of primary health care is essential to building healthy public policy and strengthening community action. This also allows for an equal distribution of care available to the local public. Individual and community involvement can also be seen through their participation through building beneficial public policy, creating supportive environments (such as in programs at community centers), and strengthening community action. It is the action of the local individuals as a group, which encourages increased community participation and support for each other, furthering positive health habits at the local level. Not only can primary health care’s focus on health promotion be seen on an external level through community action and public policy, this can also be seen on an internal level via the promotion of personal skills through education by medical professionals.

Primary care emphasizes the curative focus of medicine and mostly occurs in the clinical setting (i.e. your GP’s office, the local walk-in urgent care clinic, or the emergency department).

Primary care:

– Often is the initial point of contact between individual and medical personnel when the individual experiences a change in health status.

– Is not as comprehensive as primary care due to the acute nature of clinical visits

– Refers individuals to the services available through primary care as well as to home health care

The Take-Home, Part 1

There is a time and a place for preventative care, just as there is a time and a place for emergency medicine. The bottom line is that health statuses will always change. And when they do, stop and think. Is this something which requires long term care in my home? Can I wait until tomorrow to make an appointment at my doctor’s office? Can I drive to a walk-in urgent care clinic? Or should I call 911 and go straight to emergency? Your decision impacts not only you, but your community as well.

Mental Health Care

Continuity of therapy is a vital component of quality care for people with serious mental illnesses and must be given more attention by consumers themselves, family members, advocates, providers, administrators, and researchers alike. At the moment, there is an important opportunity to develop a national consensus statement on the principles and practice standards that should form the basis of a continuum of therapy designed to provide realistic assurance that consumers can access vital medications when and where they are needed. Important strides have been made in identifying the specific factors which promote continuity of therapy – it is time to seize this important opportunity as yet another stepping stone to achieving the transformation of America’s mental health care system for the benefit of consumers and their families, our communities, and our Nation. A roundtable of mental health experts has developed a set of nine recommendations for enhancing continuity of medication therapy for persons with schizophrenia or serious mental illness, including schizophrenia. They are as follows:

Mental Healthcare Recommendation #1 –

Encourage collaborations between hospitals and community-based organizations. Use fiscal incentives to foster collaborations including the standardization of information and shared electronic health records.

Mental Healthcare Recommendation #2 –

Use a quality improvement approach to enhance continuity of therapy by benchmarking at the organizational level performance and outcomes standards regarding continuity of care.

Mental Healthcare Recommendation #3 –

Ensure all consumers have a level of care management for the transition from inpatient to community. Care management services should be reimbursable by all payers and the disincentives to providing it should be removed.

Mental Healthcare Recommendation #4 –

Hospitals and community providers should focus on the “Pull Model” of transition from inpatient to outpatient care. The Pull Model focuses on involving community-based providers in the transition planning process from the beginning. Provider organizations should focus on staff competency in engagement and strategies and motivational interviewing.

Mental Healthcare Recommendation #5 –

Accreditation standards should be aligned to address and improve continuity of therapy in treating serious mental illness. This may include developing standards to ensure evidence of an active process of care management and transition between levels of care, a quality review of the success of transition plans, and measuring engagement.

Mental Healthcare Recommendation #6 –

Consumers and their families should be educated about the benefits of maintaining their personal health care history. Ensuring that consumers have detailed information about their illnesses and treatment history will help ensure that providers have access to the information they need to provide appropriate care in a timely manner. The options here range from simple paper and pencil logs and medication histories to electronic records on memory sticks.

Mental Healthcare Recommendation #7 –

Consumer-driven recovery planning should include and the appropriate and necessary use of hospitalization. More thoughtful use of inpatient services could lead to a reduction in emergency room use and ultimately to a decrease in the number of hospitalizations.

Mental Healthcare Recommendation #8 –

Parties who collect data about mental health services and performance should share it with appropriate stakeholders in usable and timely ways. Many payers and public entities collect both population and individual specific information about mental health consumers and services. Population-based data should be shared with all stakeholders, including families and consumers to aid in enhancing the system of care.

Mental Healthcare Recommendation #9 –

There should be meaningful involvement of consumers and their advocates in all levels of system delivery and evaluation. Global involvement of consumers and their advocates in the care delivery process is essential. Examples include using peer specialists as part of a treatment team, active involvement in policy and planning, as well as involvement in developing and implementing performance measurement and evaluation.

Applying these Mental Healthcare Recommendations –

While we have learned that maintaining continuity of therapy has a positive impact on consumer outcomes, the barriers and other impediments to ensuring this continuum of care have been long entrenched in mental health and related care systems. An unacceptably high number of people with serious psychiatric issues – including schizophrenia, depression and bipolar disorder – are “falling between the cracks” in the transition between acute inpatient settings and the community causing harm and disruption in their own lives and those of their families and often bringing their recovery process to a halt.

A continuity of therapy initiative is likely to decrease inappropriate use of emergency room services by consumers with schizophrenia or other serious mental illnesses by assuring consistency in the disease management approach used by all community provider organizations. Both of these likely outcomes of continuity of therapy provide cost reductions for the hospital and cost offset for the investments in continuity of therapy initiative and related therapies.

In addition, the continuity of therapy initiative provides the community hospital with another very tangible benefit. The continuity of therapy initiative provides the relationships, process, and infrastructure for an overall discharge planning functionality for all consumers with mental illnesses. This discharge planning functionality is a new, and critical, element in modern behavioral health standards that began in 2007.

Using the Right Family Health Care

If you notice signs of drug/substance abuse with your child, the first thing you need to do is to create a very loving and friendly environment for discussing the problem. You need to discuss your concerns with your child in a kind manner. Making a child with drug problems to speak, or preferably, say the truth is a serious task. So, you as a parent will need to be patient and exercise a great deal of wisdom. There are many reason why children abuse drugs. Below are some of the most common reasons:

Keeping Wrong Friends and Peer Pressure:

It is a statement of fact that if a child plays with a wrong company, that company can seriously and negatively affect the behavior of the child. As parents, try as much as possible to know the company your child keeps by making it OK and friendly for them to come over to the house occasionally.

Stress:

No doubt, the pressure to succeed these days is much. Also, unknowingly, parents contribute by pushing their children a little bit too far on what they believe should be achieved. As parents, you should know the strengths and weaknesses of your child, you should set reasonable goals for the child and help in achieving these goals. Also, avoid making disparaging comparisons. Such comparisons are known to crush children’s self esteem which in-turn results to depression.

Behavioral Limits and Boundaries:

Some children abuse drugs and other substances simply because their parents let them run wild. It is true that children appreciate strict behavioral limits despite the protests they put up most times. These limits gives them a more feeling of security and love. Parents should learn how to make their Yes be Yes and No, No!

How can you afford the treatment charges needed for a child with drug problems and/or how can you afford the fees needed to get quality check-ups on your child periodically by a medical professional? Easy, make use of the right family health care and medical insurance protection in the state you live. This is the surest way to help you deal with the financial challenges involved in keeping your child drug free and providing treatment where necessary. Start by comparing free quotes on family health insurance now.

High Quality Health Care

Many healthcare facilities do not focus on achieving the objective of providing high quality healthcare to patients. Some of these facilities are primarily focused on profit making. Many of these companies employ business savvy individuals to run their operational departments/business departments. Consequently, the operational managers at some hospitals, nursing homes or home care agencies may not have clinical backgrounds.

The decision to hire business savvy operational managers who have no clinical background may have an adverse impact upon the quality of healthcare in many settings. These individuals usually do not prioritize patient safety or optimal patient outcomes. Some operational managers may strategize and assign some of the functions of an operational manager to nurse managers while dictating all actions that must be taken by the nurse manager. A nurse manager who is deputized to this role may be constantly pressured by his or her non clinician superior to ensure that the facility shows a profit, or else.

High quality healthcare and profit making can co-exist. However, this seldom occurs in many places. An appropriate business model must be implemented in order for high quality healthcare and profit making to co-exist. High quality healthcare means providing care that is tailored to meet the needs of patients. Well structured health care environments have successful business models in place whereby appropriate and highly trained individuals are placed in key positions.

Individuals in key positions are those individuals charged with making important decisions within the company. Failure of healthcare businesses to utilize appropriately trained individuals within their business models may lead to dissatisfied patients, debilitation or death.

Patient Safety May Be Compromised in order to make the Numbers

The clinical staff in some settings may find themselves on different trajectory courses from the operational department. An operational manager focused on making a profit may disregard the safety needs of patients. This may not be surprising to those who work in the healthcare arena.

Nurses and Certified Nurses Assistants (CNAs) over the years have found themselves with fewer resources. Despite limitation in resources they are still somehow expected to achieve positive results. Decisions to limit resource to staff are usually made by operational managers or by nurse managers deputized to these roles.

Focusing on profit making at the sacrifice of high quality care is a common practice in healthcare settings. Some time ago, staff members in a dialysis unit were each given several pairs of gloves in a Ziploc bag. The staff was told by the non clinical operational manager that this was their quota of gloves for the day. The high risk of infection and high probability of cross contamination from blood was never factored into that decision.

One nursing home apparently pressured into cutting costs was known for its chronic absence of gloves and soap. Certain floors at that facility had the permanent smell of feces and urine.

In order to save money, the operational department at a home care agency refused to comply with the clinical manager’s directive that more than two hours of paid field training was required prior to thrusting nurses upon innocent patients. The operational manager/ account manager at the same home care agency opposed Child Protective services to be called into a home out of fear that the child’s family would get upset and remove the contract from the agency.

One nursing home advised staff that certain depleted supplies that were needed for daily patient use could not be shipped over night as the company would not pay for them. A CNA in that nursing home poignantly asserted; “The only time that we have adequate staff and adequate supplies in this place is when the State is expected to show up.”

The aforementioned acts may sound egregious to an individual with clinical training but not to someone focused on making a profit.

Cutting cost at the expensive of patient safety may result in great savings. However, the individuals who make these decisions cannot in good faith contend that their overall objective is to provide high quality healthcare to patients. Moreover, the ability to make decisions that affect patient safety and comfort also shows who has the power within certain healthcare settings.

Clinical Department’s Dilemma in not meeting the Expectation of the Operational department.

Where patient safety is compromised due to business decisions, many nurses are afraid to make reports to outside agencies. This is often in conflict with the training that nurses receive in nursing school.

Some nurses may recall that while in nursing school, there were professors who constantly emphasized that; “Nurses are agents of change.” After real life exposure to the healthcare system, some nurses may actually question this idea or refuse to believe it.

How much change can an individual nurse implement within his or her place of employment? Healthcare facilities focused on profit making are unlikely to change their policies and procedures due to a nurse’s recommendation. Often, when changes are implemented in healthcare settings, it is due to a law suit by a patient, or because of aggressive intervention by a state agency.

One New Jersey nurse was told by her nurse manager not to cause trouble when doctors refused to comply with a particular state regulation that required doctors to be present during the emergency performance of a certain procedure. The justification was that the company could not afford to lose contracts with certain facilities where those doctors had their patients. When the nurse refused to comply, the supervisor made the nurse’s continued employment with the company unbearable. Here, profit making was prioritized over patient safety.

On another occasion, a nurse was told by her manager that she was required to be productive. As such, she was instructed to leave patients during the performance of a medical procedure to do routine cleaning of equipment in another part of the department. When the nurse refused, the supervisor retaliated against her.

Employers bent on retaliation may go as far as the Texas doctor who tried to have two nurses criminally prosecuted after they reported him to the Board of Medicine.

As such, many nurses are afraid to make waves and afraid to report matters to outside agencies. Reporting matters to agencies such as the Board of Health or Child protective Services usually result in immediate loss of employment for alleged unrelated reasons.

Nurses who take it upon themselves to become “agents of change” may also find also themselves labeled as trouble makers and unable to find employment with other companies. The harsh reality is that employers still give bad references to employees. In 2013, a home care agency requested an employee reference from the hospital where an applicant was formerly employed. The hospital advised the agency that it had terminated the employee whose reference was requested, because she did not suit its needs.

Personal Sacrifices

Conscientious nurses often find that the most that they can do, is to give the best care possible, as there is little that they can do to change company policies and procedures.

More often, giving the best care possible is done through personal sacrifices. One common personal sacrifice that nurses make is working off the clock in order to complete assignments or documentation. One supervisor at a health care facility advised nurses that punching out late was the same as stealing from the company. Some nurses at that facility felt that there were too many loose ends at the end of their shifts and often punched out late. While some of nurses stayed on the clock and completed their tasks, others punched out, then went back to work to complete their assignments.

The supervisor at that facility chose not to understand that where numerous nurses were placed in the same position of not being able to complete their work, that the volume of work imposed was unconscionable. The supervisor told the nurses who complained about their situation, to just find a way to finish the work. Punching out late was not an option.

In another situation, a supervisor made it known that a particular procedure must be completed within a specified time frame. Nurses would start working off the clock as they felt that their jobs were at risk for not completing the procedure within the abbreviated time frame. These nurses punched in to work only after a substantial part of the procedure was completed. By punching in after some time had elapsed, their time cards would not reflect that they took a longer time than was mandated.

Many nurses who are forced into such behaviors often never consider making reports to labor boards.

Cutting of Corners for Survival

Limiting of resources may force staff with weak personalities into bad behaviors.

One nurse reported that during her employment with a specific Nursing home, she frequently was unable to complete her medication pass and dressing changes on time. She found herself working late several days per week. She was able to complete her tasks only by starting these tasks much earlier than recommended. The nurse later discovered that there were other nurses in the same condition who apparently found a way to deal with the situation.

Many years after leaving the aforementioned place of employment, the nurse sat down with a former co-worker to reminisce about her experience at that particular facility. The nurse asked her former co-worker, how was it possible for one nurse to give so many different medications to so many patients on one ward? Many of the medications required crushing and administration via g-tubes. The other nurse explained that such situations were generally managed by giving only those medications that were important. Simply put, some medications were never given. Surprisingly, this behavior still persists today in healthcare facilities.

Arguably, the average nurse does not engage in wrong doing. However, it would seem that facilities that place profit making above patient safety or lose focus as to why they exist, implicitly encourage these bad behaviors.

Solution

There is a solution to remodeling or creating healthcare environments where profit making and high quality patient care are equally valued. One solution is to hire only clinically trained employees to manage all aspects of healthcare facilities. This includes CEOs, account managers and administrators.

A Masters Degree in Health Care Administration program may offer courses such as Leadership Skills, Health Informatics, accounting, marketing and planning as part of the curriculum. However, none of these courses prepare individuals to connect with patients the way doctors and nurses are taught to connect. A non clinician is unlikely to lose sleep if a patient is harmed from poor quality healthcare. A non clinician operational manager may be more focused on the financial impact of a medical mistake. Consequently, the clinical training that nurses and doctors are required to undergo may be instrumental in deterring certain profit motivated behaviors that non clinicians are often willing to tolerate.

All health care management training programs that are offered by Universities should include a lengthy clinical component. All students in these programs should be required to get practical training in clinical settings before qualifying for their degrees. In-depth education about disease process, impact upon patients, appropriate nursing and medical interventions may change the mind set of these profit focused individuals.

Similarly, all medical and nursing programs should incorporate a comprehensive business and operational component. This will ensure that all persons who work in health care businesses are equally qualified and motivated to ensure high quality healthcare to patients while making a profit.

Conclusion

High quality healthcare can co-exist with big profits. However, steps must be taken to provide college level clinical training to individuals charged with managing the operational and business departments of our healthcare facilities.