Care Planning is a divisive issue in the health sector. Most funders have tried to incentivise it at one stage or another. It intuitively makes sense to take extra time to prospectively care for the most complex patients. However, as current debate in Australia would indicate, the jury is out on its effectiveness. Or is it? Have we been measuring the wrong things?
Throughout this tour, examples of proactive care for the patients stratified for complexity has been witnessed. In most instances, the care plan itself has not been heralded as the magic bullet. It is acknowledged as fundamental in a system which defaults to 10 minute reactions to acute presentations. Scheduling time to be thorough, reflective and comprehensive is necessary in patients with so many organ systems under stress.
What differentiates those systems where care planning has been successful from those where it has been middling to average is implementation. The old adage says “failing to plan is planning to fail”. Too often we wait until bad things happen to good people before we react in the health system. This is both expensive and stressful. It also pushes the cost into someone else’s budget or timeframe! This may offer a positive payoff depending upon where you sit in the system. This is why a full assessment of the outcomes is warranted.
The other wisdom which comes to mind is that a plan is not a solution. Unless it becomes lived truth for everyone involved it will just gather dust. Too often our plans have been exercises in futility. We have not thoroughly engaged the patient in shared decision making so that they take a role in implementation. More importantly, we have failed to engage meaningfully with those other care providers who inevitably touch these patients. Where is the social and voluntary sector in our care planning in Australia? This leads to failures in implementation. Finally, we may well be targeting the wrong individuals. If we care plan everyone, we overwhelm ourselves and others on the care team. If we target the easy patients or those with end stage disease, we may also miss the boat.
The most robust and impressive systems seem to be those where patients are identified through application of algorithms. These systematised approaches target those most likely to fall with no style rather than those for whom falling with style will be well supported eg cancer patients. Having identified the right group, the healthcare providers focus their collective attention on all the work which needs to be organised. This most often involves multi-disciplinary team conferences or meetings. Here the medical, nursing, behavioural, allied health and social components of care gather to bring their collective wisdom and resources to the needs of the patient now and into the predictable future.
Additionally, the repeated engagement of this group over time, shares accountability for outcomes along the patient journey. It also ensures resource alignment. This process allows the social aspects to lead when appropriate and the medical components to take the fore when dictated by patient symptoms. Being able to respond to emergent dynamics with the most appropriate resources is satisfying to the team, cost saving to the system and entirely satisfactory to patients and their families. It is more like an orchestral movement which ebbs and flows than an impassioned, discordant punk rock episode…lots of noise which leaves everyone confused and tense.
So where should Australia sit? Squarely in favour of health care planning for complex patients. This stance needs to be cognisant of the corollary need to be equally committed to appropriate implementation involving the entire spectrum of care. In the Over 75 Health Check debate our response has perhaps under performed because it is not the entire solution. Perhaps a little more funding will pump prime the system so that much better outcomes flow. They certainly have with abundance in other jurisdictions!
Tracey Johnson, General Manager, Inala Primary Care