'Reenvisioning care for the chronically ill'

This week was the third annual Healthcare Leadership Forum, which focused on leveraging evidence across the care continuum. To that end, many of the speakers at the two-day event had nursing and public health backgrounds that show how healthcare is really starting to look beyond face-to-face physician encounters.

Mary D. Naylor, PhD, RN, delivered the keynote address. Naylor is the Marian S. Ware Professor in gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing and the national program director for the Robert Wood Johnson Foundation program—Interdisciplinary Nursing Quality Research Initiative.

Engaging older adults and their family caregivers directly in their care is crucial to improving outcomes, she said. For example, many people would fill prescriptions and then providers wondered why they weren’t adhering. It turns out that when patients have numerous prescriptions from different clinicians, all those medications make people feel terrible and they just stop taking them.

“We had to work with all the clinicians involved to better manage symptoms,” said Naylor. If you take the best care plan for four chronic conditions and try to combine them, she said, you will likely end up with a plan of care that includes negative drug interactions and other problems. “It’s only when we realize what’s happening to patients as a result of several conditions that we’ll get to better outcomes.”

When healthcare focuses on symptoms rather than conditions then providers are in a position to promote better care management, she said.

“Overall findings indicate that we need to reenvision care for the chronically ill,” Naylor said. “We need to think about care systems in the community that target at risk people and are designed to index hospitalizations not rehospitalizations and the use of costly services that are unnecessary.”

Healthcare also needs to think about better follow up, she said. “When we get to better outcomes, we still need to think about this as a population that needs more than we currently provide.” Her team keeps thinking about how best to do this. “This is a population whose transitions in healthcare are so frequent that we’ve got to be able to be nimble in responding by engaging caregivers, improving symptom status and preventing acute resource use.”

Beth Walsh

Clinical Innovation + Technology editor