Improving and Reforming Long-term Care

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Improving and Reforming Long-term Care

• Part 1 The Biological Foundation
• Steven A. Levenson, MD, CMD

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Reform

• Reform is in the air
• But just what does reform aim to fix?
• Reform
• Improve by alteration or correction of errors or
  defects and put into a better condition
• Make changes for improvement in order to correct
  abuses
• Source http//www.google.com/search?hlenqdefin
  e3AreformbtnGGoogleSearchaqfoq

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Reform Hurdles

• AMA to White House Don't Dictate Care 3/9/09
• http//www.healthleadersmedia.com/content/229394/t
  opic/WS_HLM2_HR/AMA-to-White-House-Dont-Dictate-Ca
  re.html
• Any attempts by federal government to use
  evidence-based medicine to dictate how physicians
  provide individualized care would be a deal
  breaker

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Reform Hurdles

• It isnt just patients and doctors
• Health care reflects and impacts all major social
  institutions
• Education, government, economics / commerce,
  families, law
• Oversight, attempts to change performance,
  enforcement all reflect and influence health care
• Reflect beliefs and methods for example, how to
  investigate, draw conclusions, define truth,
  identify correct actions, attribute cause and
  effect

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Who Can Reform What?

• Limitations of legislatures and political
  processes in bringing about true reform
• Many of us are having trouble changing our
  thinking and actions
• Non-therapeutic substitution
• In American culture, prescriptions and
  procedures have become surrogates for real health
  care and real dialogue, Dr. Newman said. We
  need doctors and patients to conceive of medicine
  and health in a totally different way than they
  have been taught in the last 20 to 30 years.
• Source http//www.nytimes.com/2009/03/03/health/0
  3well.html?scp14sqhealth20carestcse

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Reform Efforts

• How much do current efforts really being about
  meaningful change and set appropriate
  expectations?
• Not surprisingly, current approaches are
• Often uncoordinated
• Sometimes self-contradictory
• Dont consistently result in good care
• May not define issues correctly or identify root
  causes

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Reform Prerequisites

• To reform something effectively, it helps to
  understand what we are trying to improve
• Clear issue statement
• Nature and components
• Causes of imperfections and problems
• What it should look like when done
• What should be changed or strengthened
• Options for changing things
• Obstacles to implementing reform
• Options for overcoming obstacles

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Our Subject Matter

• What will it take to do this right?
• A cohesive strategy and a meaningful plan
• Understand and apply biological foundation
• Reconsider current improvement and reform efforts
• Challenge the conventional wisdom
• Widespread, consistent accountability
• Rethink the research agenda

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Our Subject Matter

• What will it take to do this right?
• Focus attention on basic care principles and
  processes
• Promote desired performance and practice
• Suppress reductionism and jurisdiction
• Reconsider notions of competency and expertise
• Change approaches to assessing and trying to
  improve quality
• Develop biologically sound reimbursement

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What Can We Each Do?
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Solution is Straightforward
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Mostly Self-Evident
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Logically Consistent
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Little Changes Add Up
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Key Principles

• What constitutes biologically sound care?

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The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
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Homeostasis

• A key biological principle
• An organism maintains relative stability through
  constant internal adjustment
• Adequately functioning organ systems adjust to
  compensate for stresses
• Including imbalances and impairments
• Disease and organ failure may
• Cause or exacerbate imbalances
• Impair physiological reserve capacity

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Homeostasis Water Balance

• Maintaining water balance

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Homeostasis Blood Sugar

• Blood sugar regulation

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Personal and Psychological Homeostasis

• Similar to physiological homeostasis
• Individuals strive for psychological balance and
  adequate function
• To thrive in personal and social setting
• Personal and psychological homeostasis require
  adequate physical homeostasis
• Example function and mood may decline when major
  medical illness causes physical instability

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Health, Illness, and Impairment

• Health can be defined as a state of complete
  physical, mental and social well-being and not
  merely the absence of disease or infirmity -
  World Health Organization (WHO)
• http//www.who.int/about/definition/en/print.html
• Limits of health care in producing complete
  well-being (i.e., health)
• However, can have profound effects, for better or
  worse

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Key Biological Principles When Things Go Astray

• Symptoms and risk factors have causes
• Often combined effects of multiple issues
• Causes and consequences have various
  relationships
• Defining those links is crucial to providing
  safe, effective, and patient-centered care

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Biologically Sound Care

• Quality of life and quality of care are
  inseparable in all settings
• Effective care is based on linking each persons
  physical, functional, and psychosocial causes and
  consequences
• The essence of individualized (person-centered)
  care
• Requires context of underlying causes and
  consequences
• Recognizes that interventions may be beneficial,
  inconsequential, or harmful

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Causes and Consequences
Consequences ? Causes One Multiple
One / /
Multiple / /
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Causes and Consequences

• All consequences (e.g., impairments, symptoms,
  complications) have causes
• Causes and consequences occur in four major
  patterns and relationships
• Clarify links among causes and consequences
• Basis for providing care in any setting

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Causes and Consequences
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Causes and Consequences (11)

• One cause ? One consequence (11)
• No other factors involved
• Usually occurs in otherwise healthy people or
  those with minor chronic conditions
• Examples
• Fracture ? impaired mobility until fracture heals
• Fatigue ? headache for a few hours

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Causes and Consequences (1Multiple)

• One cause ? multiple consequences
• Example
• Major stroke in previously well individual ?
  impaired mobility, self-care deficit, pain,
  altered nutritional status, altered mood
• Altered family processes ?mood disturbance ?
  social withdrawal and behavioral symptoms
• COPD (advanced) ? activity intolerance, altered
  breathing patterns, impaired gas exchange,
  self-care deficit
• New and old impairments may interact to increase
  risk for additional impairments

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Causes and Consequences (Multiple1)

• Multiple causes ? one impairment
• Example
• Hydration or depression risk due to
• CVA and dementia (neurological), chronic renal
  failure (urinary), colitis related to antibiotic
  use (gastrointestinal)
• Pain due to
• Parkinsons Disease (neurological),
  osteoarthritis (musculoskeletal), side effects of
  medications used to treat hypertension or lower
  blood lipids

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Causes and Consequences (MultipleMultiple)

• Multiple causes ? Multiple impairments
• Very common in short-stay and long-stay nursing
  home population
• Example
• New stroke diabetes ischemic cardiovascular
  disease chronic renal failure medication side
  effects mood disorder ? impaired mobility
  pain social withdrawal altered nutritional
  status impaired fluid balance pain risk of
  altered skin integrity

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Linking Causes and Consequences

• Four essential steps before interventions
• 1) Characterize the disabilities
• 2) Identify causal impairments
• 3) Determine specific diseases underlying
  identified causal impairments
• 4) Discover any contributing factors
• Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric
  rehabilitation State of the Art. J Am Geriatr
  Soc 451371-1381, 1997

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Biologically Sound Care Key Underlying
Principles

• Impairments may often be prevented or improved by
  treating underlying causes
• Important to
• Identify all causes of impairments, to extent
  possible
• Determine which ones can be addressed and to what
  extent
• Choose interventions in the context of the whole
  situation, not just one symptom or risk factor
• Try to optimizenot underminephysical condition

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Biologically Sound Care Key Underlying
Principles

• Interventions may prevent or correct physical
  impairment by
• Resolving underlying cause(s)
• Improving homoeostatic balance
• Maintaining or improving physiological reserve
  capacity
• Reverse impairments
• Lessen severity or help reduce progression to
  disability

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Biologically Sound and Unsound Care

• Sound
• Care of person with Condition A Condition B
  Condition C Condition D Condition E
• ?
• Unsound
• Care of Condition A Care of Condition B
  Care of Condition C Care of Condition D
  Care of Condition E

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Care in Context

• Coordinated and integrated care of people
• Especially those with multiple issues
• Consistent with biology because it
• Takes each symptom, condition, risk, or problem
  in context
• Including sequence of events
• Identifies proper combinations of cause-specific
  and symptomatic interventions
• Promotes care that optimizes physical,
  functional, and psychosocial homeostasis

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Care in Context

• Fragmented or uncoordinated care
• Biologically unsound because it
• Approaches issues as distinct entities
• Fails to identify root causes
• Fails to address causes and consequences in
  proper context
• May cause new or additional complications while
  trying to address issues in isolation

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Patient History and Context

• What are the likely differences in cause,
  approach, and context if someone
• Gets delirium and then gets anorexia
• Gets anorexia and then gets delirium
• Has a significant condition change with change in
  mental function and anorexia at the same time

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Health Care Role

• What is the role of health care in providing
  biologically sound care?

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Implications for Care Provision

• Key goal of all health care
• Effectively integrate interventions and services
  related to physical, functional, and psychosocial
  dimensions
• Key goal of medical care
• Help individuals attain and preserve enough
  physiological function to enable the greatest
  possible personal and psychosocial function
• Within limits of whats reversible / preventable

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Reform and Improvement

• How and why do these principles affect efforts to
  improve health care?

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Essential Support for Reform

• Mutual influence between health care and all
  other social institutions
• Other social institutions and public policy must
• Reflect and respect underlying biology
• Understand what they are alleging to try to
  improve and reform
• Promoting individualized care means much more
  than just functional and psychosocial
  interventions

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Essential Support for Reform

• Less helpful efforts
• Promote interventions out of context
• Focus on fragments of the care delivery process
• For example, care planning or treatment
• Are too focused on artificial distinctions
• Such as medical and social models of care

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Long-Term Care Reform

• Problem Definition and Cause Identification

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Approach to Long-Term Care Reform

• IF biologically sound care is required in order
  to meet key quality attributes
• Safe, effective, efficient, timely, equitable,
  patient-centered
• AND only some of the care is biologically sound
• THEN
• We must focus on improving the biological
  soundness of all care, in all settings

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Approach to Long-Term Care Reform

• IF the three human dimensions are closely related
• AND long-term care only partially reflects that
  reality
• THEN
• We must focus on properly integrating and
  coordinating services in all settings
• We must suppress and reverse excesses of thinking
  about medical and social models

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Approach to Long-Term Care Reform

• IF human beings have mechanisms to maintain
  physical, functional, and psychosocial stability
  despite change
• AND long-term care only partially reflects that
  reality
• THEN
• We must ensure that care in all settings respects
  and reflectsand does not impair or damagethose
  balances

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Approach to Long-Term Care Reform

• IF causes and consequences have identifiable
  relationships, and those links are important to
  identifying care
• AND long-term care only partially reflects this
  understanding
• THEN
• We must try to get care in all settings to be
  based on identifying and linking causes and
  connecting causes and consequences

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Approach to Long-Term Care Reform

• IF biologically sound care provides treatment in
  context and as a means to an end, instead of an
  end in itself
• AND long-term care only partially reflects this
  understanding
• THEN
• We must try to get the care to be given in the
  proper context