When considering health care both presently and in the future, two related facts are quite prominent. First, not only is the U.S. population steadily growing in size numerically, but the cohort of individuals ages 65 and older also is doing so at a faster rate proportionately. Accompanying that demographic transition is the fact that huge numbers of individuals who are part of this age group are characterized by having two or more chronic health problems that fuel a demand for health care and health-related social services.
Simultaneously, over the past several decades, health care increasingly has been conceptualized as a series of independent encounters (i.e., transactions) that can be distributed nearly randomly among health care personnel in the clinical setting, e.g., a physician can be on the other side of a telemedicine screen. According to an article in the December 2022 issue of the journal Mayo Clinic Proceedings, a transactional mindset exists that treats clinicians as interchangeable parts, which especially is problematic in specialties where continuity and longitudinal care play a critical role. Consequently, this industrial-based conceptualization has been harmful to health care and has impeded progress toward quadruple-aim outcomes: enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers.
Yet, such fragmentation of care is viewed as being ubiquitous. An example of structural pressures that deprioritize relationships is the adoption of models where care is provided separately by inpatient and outpatient personnel without creating time or incentives for them to coordinate with each other. If it is believed that intentionally reshaping operations, culture, technology, and financial incentives to prioritize relationships will benefit patients, clinicians, and payers who share in the costs of patient care, how can system transformation centered on relationships be accomplished?
The authors present three foundational actions that must be advanced to reorient the care delivery system: structurally prioritize continuity of relationships, make room for relationships by removing sludge from the system, and realign reimbursement and incentives at the delivery-system level. Examples of implementation strategies and tactics in each of these three domains are provided by the authors to guide organizational leaders, policy makers, technology vendors, and other interested parties.
One of the most fragile points of disjuncture within the health care system occurs at hospital discharge. In a system that radically is reoriented around relationships, the patient would not be discharged with the attendant risk of being unable to arrange necessary follow-up appointments or being seen by clinicians who lack information about the recent hospitalization. Instead, the patient would leave the hospital with actual appointments (date, time, and location) for all follow-up required to continue care safely. Systems would be built to communicate with the ambulatory clinic to arrange these appointments.