Discussion – Overcoming Barriers in Chronic Care Management

 Discussion – Overcoming Barriers in Chronic Care Management

Interdisciplinary collaboration is the cornerstone behind the management of such complex, chronic conditions by borrowing from a diverse array of healthcare providers armed with specialized knowledge and skills toward comprehensive and coordinated care. This often involves management between the Inland Family Healthcare Center, Upland, California, and specialists in disciplines such as cardiology, endocrinology, and nephrology in the professional management of chronic diseases like diabetes, hypertension, and chronic kidney disease. These specialists contribute to the necessary insights that shape the patients’ treatment planning to suit their individual needs for quality care that ensures better patient outcomes.

Notwithstanding the important work that these specialists play, many barriers restrict the patient from following up with specialist referrals and subsequent follow-ups with the primary care physician. Financial reasons remain one of the major barriers to such subsequent follow-up with specialists and primary care physicians in the case of those patients who remain uninsured or underinsured also, according to Frazier et al., 2022. Such delays in care or missed appointments due to the high cost of specialist consultations, diagnostic tests, and treatments have the potential to worsen the chronic condition, leading to poor health outcomes. According to Hu et al. (2021), financial barriers are a major contributor to underutilization among the low-income population of specialist services and thus contribute to the suboptimal management of chronic diseases. Other significant challenges include movement concerns, especially in elderly and disabled patient populations. Wolfe et al. (2020) conducted a study to determine the relationship between transportation. They missed medical appointments, and the outcomes revealed that transportation challenges are closely related to missed appointments in rural and other underserved urban centers where individuals have no access to public transportation.

Notably, some patients also have poor health literacy and may not appreciate the importance of referral to a specialist or follow-up appointments. In such situations, comprehension turns to poor adherence, where the patient does not understand the implications of missing an appointment or not following the prescription (Shahid et al., 2022). Coughlin et al. (2020) noted that patients with low health literacy accord with suboptimal adherence to specialists’ referral, which leads to the deterioration of the condition of concern.

Subsequently, the following strategies have been adopted to help celebrate our efforts to address the barriers that hinder our patients at the Inland Family Healthcare Center from getting the necessary care they deserve. First is engaging our team of patient navigators who assist patients in scheduling appointments, setting reminders for said appointments, and even providing transportation when needed. The team forms a vital connection between the primary care setting and specialist services, through which patients will not fall through the cracks of health care. Our clinic uses an EHR system to track patient referrals and follow-up appointments, with information tracked, the care team identifies and can contact patients who might need further support.

Furthermore, in promoting healthcare equity and access, we have been in partnership with local programs that provide financial and logistical support to our patients. One such example is the Riverside County Medical Association Access to Care Program (https://www.rcma.org/programs), which provides low or no-cost specialist care for eligible, uninsured patients. The program is important in enabling the lessening of financial barriers that patients go through in receiving specialist care. Other resources to support such patients include the Community Health Action Network (https://chanhd.com/), which provides transportation to patients with mobility limitations or those living in a rural community to ensure their arrival at appointments without extreme burden.

Conclusively, while the obstacles to ensuring that patients follow through on specialist referrals and follow-up appointments are enormous, the strategies utilized at the Inland Family Healthcare Center work to transcend these barriers. By meeting our patients at their degree of need on financial, logistical, and educational levels, we can provide far more comprehensive and equitable care, thereby improving patient outcomes and quality of life.

References

Coughlin, S. S., Vernon, M., Hatzigeorgiou, C., & George, V. (2020). Health Literacy, Social Determinants of Health, and Disease Prevention and Control. Journal of Environment and Health Sciences, 6(1), 3061. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889072/#:~:text=Individuals%20with%20low%20health%20literacy

Frazier, T. L., Lopez, P. M., Islam, N., Wilson, A., Earle, K., Duliepre, N., Zhong, L., Bendik, S., Drackett, E., Manyindo, N., Seidl, L., & Thorpe, L. E. (2022). Addressing Financial Barriers to Health Care among People Who Are Low-Income and Insured in New York City, 2014–2017. Journal of Community Health, 48(2). https://doi.org/10.1007/s10900-022-01173-6

Hu, H., Jian, W., Fu, H., Zhang, H., Pan, J., & Yip, W. (2021). Health service underutilization and its associated factors for chronic diseases patients in poverty-stricken areas in China: a multilevel analysis. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06725-5

Shahid, R., Shoker, M., Chu, L. M., Frehlick, R., Ward, H., & Pahwa, P. (2022). Impact of low health literacy on patients’ health outcomes: a multicenter cohort study. BMC Health Services Research, 22(1), 1148. https://doi.org/10.1186/s12913-022-08527-9

Wolfe, M. K., McDonald, N. C., & Holmes, G. M. (2020). Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997–2017. American Journal of Public Health, 110(6), 815–822. https://doi.org/10.2105/ajph.2020.305579

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Discussion – Overcoming Barriers in Chronic Care Management

Discussion Prompt
Interdisciplinary collaboration is crucial for the care of complex chronic patients. Name the specialists or consultant fields that you most frequently contact for care of chronic patients you’ve seen in the past. What are the barriers your chronic patients face in regard to following through with referrals to these specialists as well as follow-up with their primary care manager? Explain the methods and personnel involved in your specific clinic for assisting with and monitoring follow-up appointments and referral completion.
Describe some strategies to increase successful follow-up and referral completion by your clinic’s patients, keeping in mind healthcare equity and access for all patients. Include the names and links of at least two specific programs or resources in your area, and patient eligibilty for the program or resource.

NAME OF MY CLINIC SO IT WILL LOOK MORE SPECIFIC IS : Inland Family Healthcare Center in Upland California