We invite you to read our latest “Partnership Perspective” on the benefits and possible pitfalls of efforts to promote collaboration in the delivery of health and community services.
The need for coordination of effort has probably never been greater as illustrated by recent federal, state and county efforts to advance a healthier aging experience through investment in the development and implementation of master planning initiatives. Similarly, the health and aging service communities are grasping for cost-effective solutions to challenges resulting from increasingly limited resources and growing demand – as well as the burgeoning transition from institutional to community based service.
The following blog provides some reflections on collaboration and perhaps some words worth heeding, as we progress in our efforts to achieve a better integration of services and more favorable outcomes for all of us caregivers and care recipients combined.
At some point, we are all likely to wear at least one of those hats!
Please leave us your thoughts and suggestions, if any of this resonates with or contrasts with your own experience.
We are all on a learning curve and can benefit from each other’s perspectives.
One of us is an avid jigsaw puzzler who credits this avocation with encouraging an intrepid pursuit of missing pieces. They generally show up!
The New Aging Partnership was founded on the principle that we can do more together than we can individually. Such is often the case with jigsaw puzzles.
But as we turn our attention to the business of fostering collaborations within a fragmented long term care system of health care in the US, we find that collaborations may not always be effective.
The truth about collaboration is brought home very clearly in a systematic review of the impacts of collaboration between local health care and non-health care organizations and factors shaping how they work (Alderwick, H., Hutchings, A., Mays, N: BMC Public Health 21, Article number: 753 (2021)who found that although evidence on health outcome is generally limited, the evidence of impact from some kinds of collaborations was more promising, such as coalitions to reduce health inequalities among minority groups, or system changes focused on improving housing. Very promising are the findings of one study that found that integrated care interventions may improve patient satisfaction. However, the study concluded that, in general, there was a lack of evidence on health impact, perhaps because outcomes are difficult to measure.
EUREKA
Years ago a very enlightened professor of ethics instructed his students in a fundamental precept of ethical study. You judge the ethics of an act not based on the consequences, but, rather, based on the expected consequences that guide one’s actions. A subtle but very significant difference. Equally important are the values that guide one’s actions.
By the way, professional competency is a value. Failure to act with competency is unethical practice.
Values are simply preferences, and ethics refers to values in action.
Collaborations can fail because of issues associated with incompetency, but can also fail because of an absence of shared values among the collaborators. We have all seen this in our experiences.
They can also fail despite the best intentions and practices. External issues, such as turf conflicts, or an economic crisis, legislative reversals, can undermine the best laid plans. As once noted by an admired colleague, “You can only be as honest as the system will allow!”
Certain factors that impact the success potential of collaborations, and over which we have some control, are role clarity and role consensus. That way we have respect for each other’s expectations for our professional behavior. Standardized norms for behavior would also help to ensure a more coherent outcome; but, face it, we are kind of stuck with a lot of competing local, state and federal regulations, in the US at least.
The intrepid puzzler can find some room for optimism. An article from the Harvard Business Review by Robert S. Kaplan and Michael E. Porter, from September 2011, “How To Solve the Cost Crisis in Health Care” concluded that ”the remedy to the cost crisis does not require medical science breakthroughs or new governmental regulation.” They concluded, way back in 2011, that it simply requires an approach that makes patients and their conditions –not departmental units, procedures or services – the fundamental unit of analysis for measuring costs and outcomes. These authors submit that the proper goal for any health care delivery system is to improve the VALUE to the patients, including survival, ability to function, duration of care, discomfort and complications, and the sustainability of recovery.
VALUE OF TREATMENT AND CARE
Value based care has finally arrived and we would do well to consider the words of wisdom of Kaplan and Porter, but these authors still equate value with cost-effectiveness. But what if value based care is not cost effective? Do we throw out the baby with the bath water?
Perhaps social achievements are costly, and need to be considered independently of savings. Value may not come cheaply. A recent article “In Health care, More Money is Being Spent on Patients’ Social Needs. Is it Working?” asks the question, is it worth spending money if health outcomes don’t improve? But, perhaps we are asking the wrong question. Maybe helping people with housing, food and nutrition is enough (NPR.Org/sections/health-shots/2021/06/21).
Cost savings is valuable.
Improving health outcomes is valuable.
Meeting social needs is equally valuable.
If you can connect meeting social needs with better health outcomes and save money at the same time, great! Otherwise, why not pursue each objective independently? Maybe saving money needs to be relegated in favor of “finding money.”
In addition, a few other takeaways from the above discussion:
Value Consensus in Long Term Care
Here we are not just evaluating medical cost-effectiveness.
Those involved in collaborative efforts to improve long term care delivery need to agree on goals for improvement in specific areas across the continuum of care. Some goals that we have uncovered through research and experience are:
Need for Family and Informal Caregiving Support and Training
Need for Re-education of Hospital Personnel involved in Hospital –to- Home programs; and, Health Personnel, in general, in new technologies and methodologies
Need to expand resources, through community health, mental health and public health
Need to include social needs within scope of service delivery
Need for FOLLOW-UP, one of the most seriously neglected areas in service delivery.
Need to promote interdisciplinary practice and establish new roles and role relationships (i.e. expectations regarding mutual interaction of different members of the team).
Need to provide incentives for health personnel, including better pay and career ladders
Need to advocate outside the workplace for the objectives outlined above.
PS: We love the focus on patient satisfaction with service as a standard for evaluating outcomes. This is a less complex standard of performance measurement that would even sit well with the ethicists among us!
If you want to know the value of a particular service or treatment, keep it simple and observable. Did the patient survive, was treatment sustainable? A phenomenologist’s dream form of measurement! You want to know the outcome? Look with your eyes and listen with your ears.
JUST ASK!
As for the pieces, well, that takes perseverance.