project
Write a 3-page-report in which you analyze the relationships within a health care system that are necessary to achieve an organizational goal, explain how the health care system can serve as the framework for problem solving, and explain ethical questions associated with this specific situation:
The CEO of your health care organization is working with the CFO to enhance and expand the skilled nursing facility’s quality management team. You must identify the partners who would be essential in this expansion.
Analyze the relationships within a health care system that are necessary to achieve an organizational goal.
- Identify the partnerships you will need to complete your task.
- Explain why you chose the partnerships you identified. What will each contribute to your task?
- Explain how the health care system itself serves as the framework for problem solving.
- Explain any ethical questions related to your task that could arise.
Project Must include:
Title page.
References page.
APA-formatted references
3-4 pages in addition to the title page and references page.
At least 4 supporting resources.
Running
head: IDENTIFYING CONTINUUM OF CARE
1
Identifying Continuum of Care
Jake Christopher
MBA5310 – Decision-Making in the Health Care System
June 10, 2050
Running head: IDENTIFYING CONTINUUM OF CARE 2
Executive Summary
The Medicare review team of Danabby Medical Center has identified a weakness in the
organization’s approach to the continuum of care for geriatric patients. This report serves to
identify the internal and external partners needed to design a comprehensive consortium
enhancing quality across a continuum of care.
Running head: IDENTIFYING CONTINUUM OF CARE 3
Table of Contents
Executive Summary 2
Relationship Analysis 4
Problem Solving Framework 4
Conclusion 6
References 7
Running head: IDENTIFYING CONTINUUM OF CARE 4
Relationship Analysis
The Medicare review team of Danabby Medical Center has identified a weakness in the
organization’s approach to the continuum of care for geriatric patients. The senior leadership of
Danabby Medical Center recognizes a systems approach as the solution to enhancing quality
across this continuum of care. This approach requires the development of a consortium of
internal and external partners to address the multiple health concerns typical to the geriatric
patient population. The U.S. Department of Health and Human Services (n.d.) has identified
fostering such partnerships as key to developing a person-centered care plan that is based on the
individual’s treatment and outcome goals. Managing medications; synchronizing comprehensive
home, facility, and community-based services; addressing complex psychosocial needs; and
coordinating financial resources are key to successfully treating patients with multiple physical
health problems (HHS, n.d.).
The goal of any person-centered care model is to identify health issues as early as possible to
provide the least restrictive and least intensive level of care to treat the current condition. By
creating a collaborative consortium of internal and external provider partners, a systems
approach to healthcare delivery would eliminate access issues while ensuring proper utilization,
providing quality care in a cost-effective manner. It would diagnosis and treat conditions long
before hospitalization is required or shorten the length of stay in a hospital setting.
Given this, the primary clinical internal partners needed to address the continuum include, but
are not limited to: physicians, nursing, physical therapists, occupational therapist, pharmacy,
diagnostics, the Emergency Department, and case management. These clinical professionals
currently work well together creating a comprehensive care plan with the patient and family that
supports recovery and wellness. However, in order to sustain positive health outcomes long term,
a well-coordinated, community-based, seamless care delivery system needs to be developed. The
absence of such a delivery system has been identified as the weakness to the organization’s
approach.
The external partners could include at home care, family care givers, physician practices,
skilled or rehabilitation long term care facilities, public health, residential treatment facilities,
assisted living, outpatient rehabilitation, home health, chiropractic, outpatient clinics, psychiatric
counseling, and tele-health physicians. When properly utilized in a coordinated care effort, each
of these services has a vital and diverse role in the delivery of healthcare.
Problem Solving Framework
Danabby Medical Center uses the DECIDE model for decision-making. As such, it has
initiated this process to identify specific weaknesses in the organization’s approach to the
continuum of care for geriatric patients. The senior leadership of Danabby Medical Center
created an internal committee comprised of representatives from the different internal partner
areas. They are currently engaging the DECIDE model focused on continually identifying
weaknesses in the organization’s approach to the continuum of care for geriatric patients. This
Running head: IDENTIFYING CONTINUUM OF CARE 5
committee is charged with D = defining problems, E = establishing criteria, C = considering
alternatives, I = identifying the best alternative(s), D = developing and implementing a plan of
action, and E = evaluating and monitoring the solution providing feedback for adjustments (Guo,
2008). One of the problems defined includes a bottleneck in facilitating patient transfers to a
lesser level of care. This results in patients staying in a more intense and more expensive level of
care longer than necessary. The leadership of Danabby Medical Center wishes to introduce the
DECIDE model to its consortium partners to help identify other weaknesses. It also wishes to use
this as a framework for developing procedures to best facilitate appropriate transfers and proper
service utilization at every level.
Danabby Medical Center seeks to incorporate systems thinking in all their decision-making
endeavors. Though this is a natural process internally, Danabby Medical Center recognizes the
need to help develop the culture of systems thinking within its consortium. It will utilize its
internal training and organizational development resources to help introduce both the DECIDE
model and the systems approach to solving problems to its external partners. The systems
thinking framework is outlined by Patricia Trbovich (2014) and notes utilizing a systems
approach to solving problems while understanding system-wide effects. It promotes proactive
approaches while creating a culture of sustainable systems thinking.
Fostering an overall process of collaboration and systems thinking will create an incredible
foundation for developing a supportive health care provider community. This will then well-
position organizations for value-based revenue sharing models and enhanced community
wellness initiatives.
Ethical Questions
The key to the success of any healthcare initiative is to involve patients and their families in
the decisions, empowering them to be partners in their own care (Institute of Medicine, 2001).
The medical ethicists Beauchamp and Childress (2012) illustrate four basic principles that offer
guidelines to this end. First, they start with the concept of autonomy that conveys each patient
has a right to choose their care based on personal values. Beauchamp and Childress continue to
suggest that all care initiatives are for the patient’s good followed by the universal medical
ethical principle of ‘do no harm’. Finally, they suggest the final ethical principle as healthcare
resources should be equally distributed and that all patients should be treated fairly.
Though the emphasis of the consortium’s work will be ethical and confidential, ethical
questions related to enhancing the continuum of care for geriatric patients could arise. Using the
four basic principles as a framework, we start with the first principle: autonomy. In all efforts at
every level of care, the right of the patient to retain control over their own body is paramount.
The health teams can advise, educate, and suggest courses of care, but the end resolve falls to the
patient’s personal decision. So, attention must be given to not coerce patients into treatment,
even if their decision goes against accepted medical practice. So, the ethical question here is
whether the treatment honors the patient’s decision.
The second principle states that healthcare professionals must do all they can to benefit the
patient in all situations. To do this, clinicians must maintain a high level of knowledge and skill,
Running head: IDENTIFYING CONTINUUM OF CARE 6
utilizing accepted best practices. They must do this while considering the patient’s individual
circumstance, values, and beliefs. This helps enhance patient outcomes while complying with
regulations and mitigating risks. So, the ethical question here is whether the care delivery follows
best practices while honoring patient decisions.
The third principle states ‘do no harm’. To address this, it is best for all organizations to
implement strong risk management policies, safety procedures, and clinical best practices
protocols for all staff and partners to follow. So, the ethical question here is whether such
policies, procedures, and protocols exist and are they monitored for compliance and
effectiveness.
Finally, the principle of fairness and a stewardship of resources can present some ethical
questions particularly when looking at community-wide health initiatives and highly specialized
treatments. This means having policies and procedures that provide guidance ensuring
compliance with all regulatory and legal requirements, provision of treatment to all without
exception, and fiscal responsiveness for the resources given.
In addition to these guiding ethical principles, the consortium needs to maintain
confidentiality. Though the Health Insurance Portability and Accountability Act (HIPAA)
outlines expectations of patient confidentiality, when working with a multi-organization
consortium, preserving patient confidentiality can be a challenge. This being said, another ethical
question in this endeavor includes how is the group honoring patient confidentiality while still
providing the care needed to best serve the needs of the patient and their family.
Conclusion
Danabby Medical Center is taking the lead in creating a consortium of various partners to
collaboratively coordinate a continuum of care that addresses the needs of the person and their
family. Though the initial focus will be on the geriatric patient population, these efforts can be
applied to any patient population. The aim is to help patients get better quicker and stay better
longer. This consortium will focus on community wellness in both prevention and intervention,
using evidence-based care practices to ensure appropriate utilization (Kaiser & Lee, 2015). And
in this age of value-based risk sharing financial models, such a consortium will help ensure the
sustainability of healthcare services in its community while positioning all organizations for
financial success.
Running head: IDENTIFYING CONTINUUM OF CARE 7
References
Beauchamp, T. & Childress, J. (2012). Part II: moral principles. Principles of Biomedical Ethics,
(7th ed.). New York, NY: Oxford University Press.
Guo, K. (2008). DECIDE: a decision-making model for more effective decision making by
health care managers. The Health Care Manager, 27(2):118-127.
doi:10.1097/01.HCM.0000285046.27290.90
Institute of Medicine (US). Committee on Quality of Health Care in America. (2001). Crossing
the quality chasm: A new health system for the 21st century. Washington, D.C.: National
Academy Press.
Kaiser, L. S., & Lee, T. H. (2015, October 8). Turning value-based health care into a real
business model. Harvard Business Review Digital Articles, 2–5. Retrieved from
https://hbr.org/2015/10/turning-value-based-health-care-into-a-real-business-model
Trbovich, P. (2014). Five ways to incorporate systems thinking into healthcare
organizations. Biomedical Instrumentation & Technology, 48(2), 31–34, 36. Retrieved from
https://search-proquest-
com.library.capella.edu/docview/1566919058/11CBFA0EB77A4F07PQ/6?accountid=27965
U.S. Department of Health and Human Services (HHS). (n.d.) Module 1: Person-and family-
centered care. Retrieved from https://www.hhs.gov/ash/about-ash/multiple-chronic-
conditions/education-and-training/curriculum/module-1-person-and-family-centered-
care/index.html
https://hbr.org/2015/10/turning-value-based-health-care-into-a-real-business-model