Case Study Analysis: Patient Care Coordination for Chronic Conditions

Questions
Case Study Analysis:
Choose a specific chronic condition (e.g., diabetes, heart disease, asthma).
Identify a case study of a patient with this chronic condition.
Analyze the strengths and weaknesses of the patient’s current care coordination plan.

Answer
1. Introduction
At present, there is an increasing number of people with chronic diseases. The evidence for this claim is in the 133 million Americans, or almost 1 in 2 adults, living with a chronic condition, and this figure is predicted to increase by more than 30% between 2000 and 2020 to 157 million with 81 million having multiple conditions. Projections suggest that chronic diseases will account for three-fourths of the total health care costs in 2023 – more than $4 trillion (Saint T, et al 2000). Chronic diseases are health problems that require ongoing management over a period of years or decades. They include, among others, arthritis, asthma, cancer, COPD, cystic fibrosis, diabetes, cardiovascular disease, and any form of mental retardation. A recent survey identified a total of 139 million Americans living with these diseases. These chronic conditions impact the lives of the people affected in many different ways. In 2000, the Surgeon General’s report on health and behavior revealed that 22% of people living with chronic diseases had limitations in daily activities compared to 3% of those without a chronic condition. People living with chronic condition are also at risk of dying prematurely. It has been shown that 90% of Americans’ annual deaths are caused by chronic diseases and 77% of employer costs are due to productivity losses in employees with chronic conditions. Healthcare providers have also been alerted to pay special attention to their patients living with a chronic condition. In 1998, the National Health Interview Survey (NHIS) reported that 70% of visits to a doctor’s office involved treatments for people with one or more chronic condition. With a large population affected by chronic diseases, care coordination is fundamental in assisting individuals to manage their conditions and improve their overall quality of life. Care coordination is a process that encompasses a wide array of functions and services that help patients with chronic conditions manage their health. Coordination involves organizing patient care and involves information sharing and communication between all participants concerned with a patient’s health to achieve safer and more effective care. Primary care physicians and patients play central roles in care coordination. Information from The Commonwealth Fund analysis in the Tri-Annual National Survey 2007 reported that patients with chronic conditions receive better care from primary care physicians versus specialists. Primary care physicians also report that chronic care management is one of the most challenging aspects of their job. This indicates that care coordination efforts need to improve in linking the efforts of generalists and specialists for patients living with chronic conditions. Improved care coordination ensures that the patient’s needs and preferences for managing their chronic condition are met and that healthcare decisions are agreed upon and followed by the patient. Coordination also supports the self-management of patients to become more involved with their care and in turn achieve clinical and personal goals they have set to improve their overall health. With these points in mind, this paper is centered on the case analysis of a patient named Clarence, living with diabetes, and the coordination efforts between healthcare providers to improve his health outcome.
1.1. Background of the Chronic Condition
Chronic diseases can be difficult to manage. They often need a lot of health services to manage their condition. This is what we call coordination of care. Coordination of care is a fragmented and an ad hoc enterprise with little standardization from patient to patient. Good, clear communication is key to effective care coordination. This is often lacking between primary care physicians and specialists, as well as between these providers and the ancillary services that play such a large role in managing chronic disease, such as pharmacies and laboratories. The way care is often managed and coordinated across the primary and specialty care settings, hospitals, home health agencies, and nursing homes provides an array of dangerous pitfalls for the patients and is an inefficient and expensive way to manage chronic disease. The case for this patient is all too common. This elderly patient has several chronic medical problems: congestive heart failure, hypertension, diabetes, and chronic kidney disease. The plethora of medical issues alone can create its own fragmented care and care coordination impaired by the individual concerns of each specialty involved in this patient’s care. As we detailed the patient’s experience throughout the hospitalization and elegant discussion of the pros and pitfalls of each stage of this patient’s care, it became clear that the systems currently in place provide many obstacles to effective care coordination. Good communication between providers with regard to the patient’s wishes and prior discussions about the care plan is an essential early stage in caring for a patient with chronic disease. Often the patients are not always clear to the physician about their own wishes, and many patients with multiple specialty involvement may have conflicting plans on how to address various issues in their health. This is an instance in which medical decision making becomes complex and difficult. Often a decision on paper A cannot be effectively communicated to provider B. Occurrences like this can lead to the patient’s avoidance of hospitalization for re-admission for an episode of heart failure symptoms.
1.2. Importance of Care Coordination
Care coordination is important to avoid gaps, overlappings, and delays in delivering the care that we need. Coordination may avoid, for example, conflicting treatments among our specialists or duplicate tests. Information is passed on about our needs and the activities of all the people involved in our care. With good information and a clear plan, the activities of the different people involved in our care are more structured and productive. Any changes in our health or the way we are managing our health problem are monitored, and the care plan is revised as necessary. In contrast, without effective care coordination, it is left to us to tell different health professionals what other health professionals are doing for us. We and our family members are forced to understand and keep track of the care that we are receiving and to recognize when it is not going well. Oftentimes, healthcare providers are not even informed about certain treatments or tests that the other providers have ordered. Good care coordination can prevent such burdens on patients and communication errors among providers. Information about changes in the patient’s health can fall through the cracks, with the result that no one takes responsibility for revising the care plan. A chronic care patient’s best choice among treatment strategies may not be considered because different providers are acting independently and no single professional takes responsibility for synthesizing the opinions of the various specialists involved.
2. Case Study Overview
2.1. Patient Profile
2.2. Description of the Chronic Condition
3. Current Care Coordination Plan
3.1. Care Team Composition
3.2. Communication and Information Sharing
3.3. Care Plan Implementation
3.4. Monitoring and Follow-up
4. Strengths of the Current Care Coordination Plan
4.1. Effective Communication Channels
4.2. Comprehensive Care Plan
4.3. Regular Monitoring and Follow-up
5. Weaknesses of the Current Care Coordination Plan
5.1. Fragmented Communication
5.2. Lack of Patient Engagement
5.3. Inadequate Care Plan Updates
6. Opportunities for Improvement
6.1. Enhanced Communication Strategies
6.2. Patient Education and Empowerment
6.3. Integration of Technology
7. Recommendations for Care Coordination Enhancement
7.1. Strengthening Interprofessional Collaboration
7.2. Implementing Patient-Centered Approach
7.3. Utilizing Health Information Exchange
8. Conclusion