Patient Centered, Interdisciplinary, and Cost-Effective: Can We Do It All?

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• Dr. Barbara Resnick

We are all affected, directly or indirectly, by our current economic downturn. For some individuals, this may be related to salary cuts, furlough days, positions lost, or hiring freezes. As nurses, we are having to learn to manage with less yet provide care that meets an ever-growing list of requirements and standards. How can we do it? Is it possible?

Never resisting a challenge and trying to see the opportunity in all that comes our way, I believe we can make positive changes. We may just have to get back to basics and focus on what is really important. The solution to this all comes in the form of communication, team work, and eliminating futile care.

Patient-centered care ideally begins with listening to the patient or resident (or, in cases when he or she is no longer competent, we listen to a proxy)—getting a real sense of what the individual wants. After wants and needs are identified, a realistic plan can be developed. In some cases, negotiation may be necessary because it is not possible in a community setting for everyone to have what they want. Even in simple matters such as having fish on Friday, getting a flu shot by a certain date or time, watching a certain television show, being able to use a heating pad, or getting into bed at 7 pm, negotiation may be required. Not everyone always wants fish on Friday, yet did you or do you always make a separate meal for everyone in your family? Is it cost-efficient and practical to do that? The best alternative may be to have fish every other Friday. Likewise, if 10 residents on a unit want to go to bed at 7 pm, it may not be humanly possible to help everyone get into bed at the same time. A rotating schedule may be the best alternative. In a community setting, what is good for one individual may cause misery for another. Resident-centered care must therefore be tapered with community-based negotiations to realistically achieve what everyone wants. Honesty about resource allocation and open discussions about what and how needs will be met will help residents and families understand how and why care is being provided in the way that it is.

Listening to what patients/residents want in terms of treatment options is also critical and can save time and money. “Slow medicine” and avoiding medical futility are ethically sound and useful approaches to patient-centered and cost-effective care. There are people, however, who want every possible intervention available, even when the outcome is not likely to return the individual to his or her prior state of health or functional capacity. These can be the most challenging cases. Medical futility is described as proposed therapy that should not be performed because available data show that it will not improve the patient's medical condition.¹ Health care providers have a responsibility to all Americans to refuse to provide care when it can be proven to be medically futile. There are, however, no legal requirements to provide or withhold such services. Given the high cost of care in these situations, such policy may become central to cost-efficient care in the future. In the meantime, through ongoing communication and education, mutually agreeable decisions can be achieved among the health care team, the patient or resident, and/or the proxy.

Teamwork, at a time when there are limited resources, is a natural and logical solution to meeting the care needs of an ever growing aging population. Teamwork, if executed correctly, can be cost-effective by matching ability with task and using the expertise of multiple disciplines. This crosses levels of ability and knowledge within as well as between disciplines. For example, this might include identifying who can do an initial assessment of a resident in any type of care environment, who can best complete medication reconciliation, who helps to facilitate integration into the facility, and who is best suited to provide direct care including such things as wound care, optimizing function in residents, and overseeing and giving medications. Some of the decisions around who can do what are based on scope of practice at the state and national level. There are times, however, when scope issues need to be reconsidered in the name of good, safe, and affordable patient care. There was a time, for example, when only physicians could take blood pressures. Times change and care changes. In some states, nursing assistants can perform tasks such as catheterizing patients or performing wound care. In other states, these activities can only be done by nurses. Likewise, in some states, nursing assistants can give insulin injections, and in others, nurses must perform this task. Scope and practice issues affect access to care and lead to higher costs (e.g., the individual who has to move out of assisted living into a nursing home because of a need for injectable insulin with no nurse available to provide that treatment).

Although scope of practice is a major barrier to cost-efficient and effective team-based care, an equally frustrating problem is what health care team members will allocate to other members of the team and what they will trust other members to perform effectively. A nurse, a pharmacist, or a physician might each perform a past medical history and medication reconciliation at the time a resident is transferred into a long-term care facility. Does it make sense for three individuals to perform the same task? Is there a way we can begin to trust each other and hold each other accountable for the work that is done? If we reach out and teach, within and across disciplines, we may be able to develop the skills and expertise of team members so that we feel comfortable delegating tasks (within scopes of practice, of course). In addition to being cost and time saving, it would improve access to care and the quality and level of care provided. I strongly encourage state boards of nursing to consider the role of the advanced nursing assistant to help meet the more complex care needs routinely required in long-term care settings.

As we think about the team and cost-effective and efficient care, reimbursement issues cannot be ignored. Nurses are generally salaried and may or may not directly relate their care services to reimbursement in any care setting. For physicians, nurse practitioners (NPs), consultant pharmacists, and social workers, reimbursement issues become more critical. We need to work together to ensure adequate reimbursement for services to meet care needs and cover the critical indirect costs of care. I believe a good team can optimize billing rather than resort to competitive billing. Team members can case find for each other and refer appropriate services, rather than compete for the same service. One may have skills in a particular area, for example, and thus can provide that type of care quickly and efficiently. We can—so to speak—play together in the sandbox.

I am not alone in my desire to reach out and work with other members of the health care team. The American College of Physicians (ACP) recently released a new policy on NPs in primary care. Although it is not a geriatric-focused policy, the ACP has acknowledged that both NPs and physicians must play a critical role in improving access to patient-centered health care. Both groups, they state, must work together as teammates, with mutual respect for the unique contributions and skills offered by each profession. Specifically ACP indicated that they “recognize the important role that NPs play in meeting the current and growing demand for primary care, especially in underserved areas. As trained healthcare professionals, physicians and NPs share a commitment to providing high-quality care.” The Workforce Alliance has likewise come together as a group of 25 national organizations dedicated to working together to address workforce issues and optimize the care provided to older adults.

So, as difficult financially as the coming years may be, we have an opportunity to use this time to think TEAM and to explore ways that we can change policy, scope, and practice to provide the optimal care older adults need in a cost-effective and efficient manner.

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References 

1. Bernat JL. Medical futility: definition, determination, and disputes in critical care. Neurocrit Care. 2005;2:198–205
2. Barclay L. American College of Physicians issues new policy on nurse practitioners in primary care. Medscape Medical News. Available at www.medscape.com/viewarticle/588914. Cited March 2009.