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Wednesday, Mar 27, 2024
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Time to Reform Chronic Care System

If you care for a loved one with a chronic disease, no doubt you know that the system is sick. Four common chronic conditions , hypertension, asthma, heart disease and diabetes , present a significant public health challenge in San Diego.

Physicians who treat the chronically ill and people with chronic illness are increasingly dissatisfied with the health care process, including problems in communicating results of examinations, coordinating follow-up care and ensuring that prescription directions are followed.

A new AARP Public Policy Institute survey of chronically ill patients and their caregivers finds health care poses significant challenges for the 72 million baby boomers with chronic conditions.

Chronic conditions are often preventable and take a terrible toll on millions of Americans. Our fragmented health care system makes it incredibly difficult for chronically ill patients and caregivers to get the appropriate care they desperately need.


Poor Communication

The survey highlights the lack of coordination that exists within the U.S. health care system. Twenty-one percent of chronically ill patients felt their health care providers did not do a good job communicating with each other, and 20 percent said their health had suffered as a result. Uncoordinated care, among other factors, resulted in medical errors for 23 percent.

AARP’s report highlights problems that frequently occur when patients move from home to a hospital, between facilities, or back into their home. It found that poor communication between health care providers often results in medical errors or duplicative tests and treatments. Similarly, poor communication between providers and patients contributed to readmissions for 15 percent of patients.

Other findings were:

Twenty-six percent of chronically ill patients lack confidence in the health care system.

Thirty percent said their health care provider did not have the necessary information when they arrived.

Sixteen percent received unnecessary medical tests.

To address these problems locally, UC San Diego Extension and the county have been working with physicians, nurses and others to better manage the complicated treatment of those with chronic illnesses. The program, Team San Diego, emphasizes team-based care in a health care system that’s increasingly fragmented and built to deliver acute care.


Policy Changes

We concur with the several AARP recommendations for policy changes to improve care for the chronically ill, including:

Increasing the use of health information technology so doctors, patients and caregivers have the information they need, when they need it.

Expanding testing of care delivery models to find what works and including best practices for chronic disease care in training for doctors and other health professionals.

Making innovative changes to payment policy to encourage better performance and outcomes.

Making preventive care and medications more affordable to avoid preventable chronic diseases altogether and better treat those that do occur.

Chronic care patients are likely to have multiple issues and illnesses that involve many people in their care. It’s not enough to communicate with our own colleagues and staff. To do their jobs successfully, health care professionals must communicate better with patients, other staffs and culturally diverse populations.

Without support for community care teams, providers will soon be crushed under an avalanche of the increasing numbers of chronic care recipients.

But if the local program proves successful, the research can be used to help cure chronic care programs nationwide.


Mark Meiners is a professor at George Mason University and serves as principal consultant to the county of San Diego Aging and Independent Services on long-term care integration. Grace Miller is director of Healthcare and Behavioral Sciences education at UCSD Extension. They are part of Team San Diego, a consortium of providers and patients working together to improve care coordination of medical and social services for people with chronic conditions.

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