Fragmentation as a never event

In healthcare, fragmentation is on of the more pervasive drivers of inefficiency and ineffectiveness.

Take for example the following well-written piece by Dr. Kurt Stange published in Annals of Family Medicine:

“A wealthy man I know went from doctor to doctor to try to find a reason for his fatigue. Each doctor looked in depth at the organ in which (s)he was an expert. Each did the latest tests.Each prescribed the latest drugs and devices. And the patient,the person, got worse. He was in charge of his healthcare; he bought the best of each commodity; but in the end his fatigue remained and he only felt more alone.”

At the heart of good healthcare is the importance of a relationship with your health and healthcare team. Much has been written about the importance of continuity in healthcare. The sad thing is that in the current system, volume is appreciated over value. When healthcare begins to value the relationship, and can accommodate the forming of relationships, will we have made an impact on some of the problems plaguing the system? Fragmentation often does not nurture relationships.

Recently in Health Affairs, there was article on “Medical Homelessness. ” A personal story of not having a consistent home in healthcare was highlighted, and the dangers of not having this home was discussed. As a matter of fact, at one point the author even asks “Who’s Your Doctor?”

There is an essential role for primary care in the medical home and the larger healthcare system. Avoiding medical homelessness does not stop just with identifying a primary care provider though that is important. It goes into details like “will this primary care provider address my whole person needs?”

Back to fragmentation. Let’s briefly take for example the artificial separation between mental health and physical health.

Since it is well established that more mental health is seen in primary care than anywhere else, finding a true medical home may start to be more inclusive of mental health and substance use than ever before. Some have said that room must be made in the medical home for mental health, and there is no doubt that if the primary care setting wants to end medical homelessness, they must finally face the inseparability of mental health. If they do not, then we will continue to see fragmentation and addressing only pieces of the whole person in just one room of the house.

What are some solutions that we can begin considering to combat fragmentation and make it, in the words of Dr. Mac Baird, a “never event”?

Consider some of the brilliant mental health integration work happening across the country.

Cherokee Health Systems in Tennessee is proving robust onsite mental health care in primary care. They get it, and have been battling fragmentation since the 1970s.

The University of Massachusetts Medical School training program in integrated primary care has been retraining mental health providers to work in primary care for over a decade. By turning out new mental health providers to work in primary care, UMass and company are battling fragmentation.

The list of innovators goes on and on.

Again Dr. Stange: “Underlying the current healthcare failings is a critical under appreciated problem: fragmentation—focusing and acting on the parts without adequately appreciating their relation to the evolving whole. This unbalance, this brokenness, is at the root of the more obvious healthcare crises of unsustainable cost increases, poor quality, and inequality. Fragmentation is at the heart of the ineffectiveness of our increasingly frantic efforts to nurture improvement.”

Isn’t it time fragmentation became a never event?

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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  • http://www.spherit.com Spherical Phil

    Dr. Stange is correct, it is about the whole, both patients and providers seeing the whole of their health/well-being, seeing how every aspect of their being; physical, mental, emotional and spiritual come together to shape the person’s “health.”

    But we don’t talk about the whole. We don’t know what whole is in health (or life, relationships etc) much less know how to see it, embrace it, engage the whole.

    It is a bit complex, but can be done, but not how we are approaching things today. What is so interesting is that in seeing whole, by both patients and providers we have seen dramatic, discontinuous improvement in their lives while decreasing costs.

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