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Navigating the Health Care System Jonathan M. Evans MD MPH Chief, Geriatric and Palliative Medicine University of Virginia.

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Presentation on theme: "Navigating the Health Care System Jonathan M. Evans MD MPH Chief, Geriatric and Palliative Medicine University of Virginia."— Presentation transcript:

1 Navigating the Health Care System Jonathan M. Evans MD MPH Chief, Geriatric and Palliative Medicine University of Virginia

2 Goals Discuss health care delivery in The United States Discuss health care delivery in The United States Discuss strategies to help you get better care Discuss strategies to help you get better care Discuss strategies to help you retain some power and control of your life while in health care settings Discuss strategies to help you retain some power and control of your life while in health care settings

3 What is a health care system? Integrated system whereby a person receives all of the care they need to meet their healthcare needs, promote health and wellbeing, improve quality of life Integrated system whereby a person receives all of the care they need to meet their healthcare needs, promote health and wellbeing, improve quality of life Patient-centered Care provided in a coordinated manner among all of the clinicians involved, working together as a team Patient-centered Care provided in a coordinated manner among all of the clinicians involved, working together as a team Requires careful planning, oversight, cooperation, communication among knowledgeable, motivated participants Requires careful planning, oversight, cooperation, communication among knowledgeable, motivated participants

4 Whats wrong with our health care system? We dont have one We dont have one Disparate pieces Disparate pieces Problems with access, availability of care quality, care coordination, oversight, service, communication, education, cost, ignorance, inadequate number and quality of staff Problems with access, availability of care quality, care coordination, oversight, service, communication, education, cost, ignorance, inadequate number and quality of staff Lack of capacity Lack of capacity Little accountability Little accountability Nobody in charge Nobody in charge No planning based upon patient care needs No planning based upon patient care needs Problems with mission Problems with mission Conflicting priorities, goals Conflicting priorities, goals Loss of power and control Loss of power and control Overtreatment and undertreatment, often simultaneously Overtreatment and undertreatment, often simultaneously Needed care, patients themselves are changing Needed care, patients themselves are changing One Size Fits All One Size Fits All

5 Fragmented care Fragmented care Across your body Across your body –Medical specialization by body part –Roles, responsibility divided among many individuals, disciplines Across town Across town –Care of a single episode of illness fragmented across multiple sites, multiple providers within each site –Medical specialization by site of care (ER, ICU, Hospital, Office, Nursing Home)

6 Care Sites Office (ambulatory clinic) Office (ambulatory clinic) Acute Care Hospital Acute Care Hospital Specialty Hospitals Specialty Hospitals Acute Inpatient Rehabilitation Hospital Acute Inpatient Rehabilitation Hospital Long-term Acute Care Hospital (LTACH) Long-term Acute Care Hospital (LTACH) Skilled Nursing Facility Skilled Nursing Facility Intermediate Care Facility Intermediate Care Facility Home Health Home Health Assisted Living Facility Assisted Living Facility Continuous Care Retirement Community (CCRC) Continuous Care Retirement Community (CCRC)

7 Licensed Care Providers Physicians Physicians Physician assistants Physician assistants Nurse practitioners, advance practice nurses Nurse practitioners, advance practice nurses Registered Nurses Registered Nurses Licensed practical (vocational) Nurses Licensed practical (vocational) Nurses Nursing Assistants/ Personal Care attendants Nursing Assistants/ Personal Care attendants Physical, occupational, speech therapists Physical, occupational, speech therapists –Therapy assistants Psychologists Psychologists Licensed Clinical Social Workers Licensed Clinical Social Workers

8 An Episode of Acute Care Prior to 1989 Prior to 1989 –Hospitalization for entire episode from onset to resolution –Hospitals paid by the day for room and board, nursing care and supplies –hospital was only site for intravenous therapy, most diagnostic testing After 1989 After 1989 –Care of illness across multiple settings –Hospitals paid by the diagnosis Lump sum payment to hospital regardless of length of stay –Hospital length of stay much shorter –Hospitalization only after other treatment has failed –Discharge from hospital prior to complete resolution –Home health care or post hospital placement usually necessary Hospitals still paid separately for diagnostic tests, procedures Hospitals still paid separately for diagnostic tests, procedures

9 Health Care Economics Expensive, labor intensive Expensive, labor intensive Shortage of trained professionals in all disciplines Shortage of trained professionals in all disciplines –800,000 more nurses needed now Shift toward lower cost workers with less training Shift toward lower cost workers with less training Emphasis on maximizing efficiency, productivity limits access, availability of care at all sites Emphasis on maximizing efficiency, productivity limits access, availability of care at all sites Focus on technology, procedures rather than knowledge, skill, listening, observing, thinking Focus on technology, procedures rather than knowledge, skill, listening, observing, thinking Mismatch between economics (market forces) and patient needs creates conflicts of interest Mismatch between economics (market forces) and patient needs creates conflicts of interest Quality, availability, and low cost of care at odds with one another Quality, availability, and low cost of care at odds with one another

10 Changing Health Life expectancy has increased by 40+ years over last century Life expectancy has increased by 40+ years over last century –Preventive health, public safety, sanitation, nutrition biggest contributors –Advances in medical care have transformed once fatal illnesses into chronic diseases Health care system (hospitals and medical offices) designed around care of a single (acute) problem in isolation Health care system (hospitals and medical offices) designed around care of a single (acute) problem in isolation Complaint-based system Complaint-based system Population of patients now has multiple chronic conditions/concerns simultaneously Population of patients now has multiple chronic conditions/concerns simultaneously Exponential increase in prescription drug use (50% increase between ) Exponential increase in prescription drug use (50% increase between ) Hospitalization now for acute exacerbation of chronic illness (diagnosis already known prior to admission) Hospitalization now for acute exacerbation of chronic illness (diagnosis already known prior to admission) System developed for different problems/different patients than exist today System developed for different problems/different patients than exist today

11 Factors contributing to current crisis Aging, obsolescent infrastructure Aging, obsolescent infrastructure Changing health Changing health Health Care Culture, attitudes Health Care Culture, attitudes Greed Greed Ignorance- inadequate education, continuing education Ignorance- inadequate education, continuing education Labor shortages Labor shortages Financial incentives, disincentives (Medicare, insurors) Financial incentives, disincentives (Medicare, insurors) Business models- market failures Business models- market failures Access to technology Access to technology

12 Strategies to help you get better care Make your goals and needs known Make your goals and needs known Teach others about you Teach others about you Complaint based system you must ask for what you want Complaint based system you must ask for what you want Be knowledgeable Be knowledgeable Be involved Be involved Take control of your health- learn as much as you can Take control of your health- learn as much as you can Keep copies of important health care records, including diagnoses, medication lists Keep copies of important health care records, including diagnoses, medication lists Know what your medications are for, and read about side effects, interactions (pharmacist) Know what your medications are for, and read about side effects, interactions (pharmacist) Know what you are entitled to (Medicare) Know what you are entitled to (Medicare) You need advocates (many) You need advocates (many)

13 Advocacy Primary care provider Primary care provider Other members of care team Other members of care team Family Members, Friends Family Members, Friends Medicare Medicare JABA JABA Dont leave until you are ready! Dont leave until you are ready! Social Services/Adult Protective Services Social Services/Adult Protective Services Attorneys Attorneys Private care managers Private care managers

14 Choosing health care providers Check them out in advance-Do your homework Check them out in advance-Do your homework Ask people you know Ask people you know Look on internet Look on internet Area Agency on Aging/JABA Area Agency on Aging/JABA Think about what you want and need in a doctor Think about what you want and need in a doctor Interview your prospective doctor Interview your prospective doctor Dont be fooled by titles Dont be fooled by titles Visit sites of care before you need them (hospital, nursing home) Visit sites of care before you need them (hospital, nursing home)

15 Receiving Health Care Prepare in advance for office visits, hospitalization Prepare in advance for office visits, hospitalization Write down questions, concerns, goals, priorities Write down questions, concerns, goals, priorities Make lists Make lists Bring someone with you Bring someone with you Take notes Take notes Write down everyones name Write down everyones name Make sure you understand whats going on before you leave Make sure you understand whats going on before you leave Ask about next steps Ask about next steps Dont leave until you are ready! Dont leave until you are ready! Discuss visit with people you trust Discuss visit with people you trust Read about relevant health issues (internet, libraries, medical letters) Read about relevant health issues (internet, libraries, medical letters)

16 Hospitalization Potentially the most dangerous health care experience you can have Potentially the most dangerous health care experience you can have The system at its worst The system at its worst The stakes are high due to severity of illness The stakes are high due to severity of illness Drug prescribing in older patients Drug prescribing in older patients Debility caused by bedrest, immobility Debility caused by bedrest, immobility Lack of information Lack of information Lack of power and control Lack of power and control Delirium likely in >50% of patients 65+ Delirium likely in >50% of patients 65+ Patients discharged sicker and quicker Patients discharged sicker and quicker

17 Hospitalization Have someone with you Have someone with you Personalize your care Personalize your care –Know who everyone is: Name, title, role (keep a log book) –Make sure they know who you are Participate actively Participate actively Ask questions about everything (especially meds) Ask questions about everything (especially meds) Avoid sedatives/sleeping pills Avoid sedatives/sleeping pills Stay out of bed as much as possible Stay out of bed as much as possible Demand the help you need Demand the help you need Dont leave until you are ready! Dont leave until you are ready! Take control over post-discharge plans Take control over post-discharge plans Get written info before you leave Get written info before you leave Call your primary doctor while in hospital Call your primary doctor while in hospital

18 Strategies to Maintain Power and Control Plan ahead to anticipate, prevent problems, pitfalls Plan ahead to anticipate, prevent problems, pitfalls Educate yourself about your rights, entitlements, resources Educate yourself about your rights, entitlements, resources Keep your wits about you Keep your wits about you Have an advocate with you Have an advocate with you Make yourself known and understood Make yourself known and understood Show people the person that you are Show people the person that you are Personalize others (refer by name) Personalize others (refer by name) Dont let people stand over you Dont let people stand over you Identify advocates among care team Identify advocates among care team Ask regularly about prognosis, plans Ask regularly about prognosis, plans Make people explain things to you Make people explain things to you Control your environment, schedules Control your environment, schedules Ask for help from people you trust Ask for help from people you trust

19 Summary and Conclusions Health care delivery is fragmented, incomplete, often unsatisfying and sometimes harmful Health care delivery is fragmented, incomplete, often unsatisfying and sometimes harmful You deserve the best health and best care possible You deserve the best health and best care possible You have to stay well informed, participate actively, and get others involved whom you trust You have to stay well informed, participate actively, and get others involved whom you trust Ask for what you want Ask for what you want Understand your insurance coverage, how providers get paid Understand your insurance coverage, how providers get paid Take full advantage of community and other resources Take full advantage of community and other resources Be involved in advocacy, voting, civic affairs Be involved in advocacy, voting, civic affairs Talk with everyone you know about health, health care Talk with everyone you know about health, health care


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