Response – Chronic Disease Management Through Interdisciplinary Collaboration and Patient-Centered Strategies

Response – Chronic Disease Management Through Interdisciplinary Collaboration and Patient-Centered Strategies

Responding to Krizelle

Hello,

This is a great post. The detailed exploration of interdisciplinary collaboration in primary care settings vividly highlights the complex networks essential for the effective management of chronic conditions. The range of specialists you engage with, such as cardiologists and orthopedic specialists, clearly reflects the diverse medical needs of chronic patients. Moreover, your identification of transportation and forgetfulness as significant barriers resonates well with common challenges in healthcare, providing a strong basis for discussion (Warren & Warren, 2023).

Building on your observations, I would like to highlight systematically ignored aspects such as anxiety and stigma, which are psychological in nature and often make the patient reluctant to seek specialist help. In my practice, infusing primary care with behavioral health has reduced these barriers and even enhanced the extent of compliance and outcomes among patients (Rawlinson et al., 2021). How have comparable integrations been utilized in your practice? Additionally, the use of telehealth in follow-ups where a physical examination is not required may be revolutionary, especially for patients with mobility or transportation issues, thus ensuring continuity of care (Raat et al., 2021).

Indeed, the New Freedom TaxiCab Services Program is a commendable local initiative. Expanding on this, could mobile health clinics, which provide direct services in underserved areas, be a feasible addition to enhance access to necessary healthcare services in your community? What potential challenges or benefits do you foresee in their implementation?

Your insights offer a substantial foundation for further enriching our understanding of managing chronic conditions. Could you please share any specific patient success stories that highlight the effectiveness of these interdisciplinary approaches? Additionally, what strategies would you suggest to further overcome the identified barriers? Exploring these successes could provide valuable learning opportunities and inspire more effective healthcare practices.

References

Raat, W., Smeets, M., Vandewal, I., Broekx, L., Peters, S., Janssens, S., Vaes, B., & Aertgeerts, B. (2021). Cardiologists’ perceptions on multidisciplinary collaboration in heart failure care – a qualitative study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06179-9

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care, 21(2), 32. https://doi.org/10.5334/ijic.5589

Warren, J. L., & Warren, J. S. (2023). The case for understanding interdisciplinary relationships in health care. Ochsner Journal, 23(2), 94–97. https://doi.org/10.31486/toj.22.0111

Responding to Ijaz

Hello,

Great work with your post. Your insights on the integration of various specialists in ambulatory care to manage chronic diseases effectively highlight a crucial aspect of modern healthcare. The strategy of referring patients with chronic conditions to specialists such as endocrinologists and cardiologists reflects a deep understanding of the need for specialized care in managing complex cases.

You have recognized critical challenges such as transport and low health literacy that prevent patients from undergoing important referrals and subsequent care. In my experience, such problems can be resolved through community outreach programs or educational campaigns, which is similar to what you have expressed. Moreover, it is possible that other patients, by improving their digital literacy, would be encouraged to take better care of themselves, which is another viewpoint on how one can address problems with accessing health care services more broadly (Barber et al., 2019).

The centralized care coordination model shared is appealing. In addition to using social support from the clinical team, establishing a peer support system would be beneficial to patients in overcoming their issues, especially in adherence to treatment and such things as isolation. Seemingly, what we did in our clinic worked well in increasing follow-up of patients and getting them actively involved in their care (Dydyk & Conermann, 2023). In a similar case, it emphasizes the role of community support in chronic disease management, which then offers a related experience that serves to demonstrate how effective such approaches could be.

Additionally, your use of feedback mechanisms to refine health services is commendable. In my practice, leveraging patient feedback has led to enhancements in service delivery, particularly in streamlining the referral process, thus directly impacting patient satisfaction and care outcomes.

The strategies mentioned, including telehealth options and extended clinic hours, are essential for improving access to care. These initiatives have been pivotal in overcoming the logistical challenges associated with extended hours, ensuring that patients receive timely and effective care regardless of their schedules.

Your contribution provides valuable insights into the complexities of ambulatory care in chronic disease management. Could you please share more about how these strategies have been implemented in your practice and their direct impact on patient care? Looking forward, what enhancements do you envision for your care coordination model to further optimize patient outcomes, and what challenges might you anticipate in these efforts?

References

Barber, S., Lorenzoni, L., & Ong, P. (2019). Price setting and price regulation in health care lessons for advancing universal health coverage. https://iris.who.int/bitstream/handle/10665/325547/9789241515924-eng.pdf

Dydyk, A. M., & Conermann, T. (2023). Chronic pain. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553030/

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PEER RESPONSE 1:

By: Krizelle

Despite being an outpatient setting when in the primary care setting, interdisciplinary collaboration is still essential in ensuring the best patient outcomes. During clinical rotations, I refer patients out to any specialist that is required for their patient-centered treatment plan. However, common specialties I often refer patients to from the primary care setting are cardiologists, gastroenterologists, orthopedics, urologists, physical therapy, and home health. Due to the increased prevalence of diabetes, hypertension, and hyperlipidemia in the general population, many patients often get referrals to cardiology for further evaluation and management of their chronic illnesses. Furthermore, osteoarthritis and spine disorders such as sciatica and degenerative disc disease are common chronic conditions I often encounter in the geriatric population that warrant further referral to orthopedic specialists.

Chronic Disease Management Through Interdisciplinary Collaboration and Patient-Centered Strategies

Despite placing referrals for patients to receive specialized care, numerous barriers impact the ability of patients to receive follow-up care with specialists. Some of the barriers include transportation difficulties, costs of specialist care, limited availability of specialists, and lack of patient adherence to receiving specialist care (Briatore et al., 2020). When asked why patients don’t attend referral care appointments, the geriatric population often reports that transportation difficulties are a major cause. In addition, many patients of all age groups often report that forgetfulness is a major cause of why they do not receive specialist care (Briatore et al., 2020). Furthermore, patients often report that once approved for specialist care, appointment availability is often booked in full for months until they can receive their initial appointment with the specialist.

One of the methods that the clinic I am completing my rotations in performs to ensure that patients attend follow-up and referral appointments is that the clinic manager calls patients once their referral has been approved so that they are aware they can now make their initial appointment. Furthermore, I have been instructed by my preceptor to always review previous patient visit notes and follow up with the patient directly on the status of any referrals whenever I am with a patient. Since transportation is often a major barrier to patients receiving specialist care, I often ask patients about their transportation situation before submitting a referral for them. Therefore, for patients with limited transportation access, I make a specific referral request for a provider that is located near the patient to ensure that they attend their specialist appointments. By doing this, we are assisting the patient with the referral process in case any difficulties or barriers have prevented them from receiving specialist care. A strategy to increase follow-up and referral completion by patients is to educate patients about the importance of specialist care and why they need to receive specialist care. Oftentimes, patients do not understand the importance of why referrals are being made and therefore dismiss its importance in their overall health plan.

One local program that assists patients with transportation needs so that they can attend follow-up care is the New Freedom TaxiCab Services Program. This program provides eligible patients four one-way trips totalling 40 miles per month to any destination they require within Los Angeles County (Taxicab Services Program, n.d.). Eligible patients include any disabled adult or any individual who is at least 65 years or older (Taxicab Services Program, n.d.). Another local program is the Long Beach Multi-Service Center which assists patients who are homeless or at risk of being homeless to find resources such as case management, housing services, homeless prevention, employment assistance, harm reduction services, and mental health support (https://www.longbeach.gov/homelessness/homeless-services/). Although this program does not directly ensure that patients attend their specialist care, assistance with case management has the potential to aid homeless individuals receive the resources they need to achieve better health.

PEER RESPONSE 2

BY: IJAZ

Ambulatory care is crucial when dealing with complicated chronic diseases through the integration of various specialists. To illustrate, the moment I see that a patient with chronic complicated medical conditions needs more attention, I usually refer to endocrinologists, cardiologists, nephrologists, and pain management specialists. These specialists offer invaluable guidance on diseases including diabetes, cardiovascular diseases, renal diseases, and chronic pain disorders that complicated patients may have (Danilov et al., 2020).

However, patients with chronic conditions experience several obstacles that make it difficult for them to complete specialist referrals and follow-up on primary care. Those include transportation problems for rural patients, costs of copayment or losing their wages, and difficulties in managing healthcare systems. Also, some patients have low health literacy and are unable to comprehend why follow-up appointments are necessary (Davidson et al., 2022).

In our clinic, for instance, we have incorporated a centralized approach to care in helping complete follow-up visits and tracking the referral processes. In this process, our care coordinators have a crucial and main role. Patients can be contacted through phone or text to remind them of an appointment, assist in booking transportation where necessary, and check on patients in cases where they missed an appointment. We also have an electronic health record system that has an alert feature that reminds the practitioner of any follow-ups that have not yet been arranged to enable us to follow up with the patient.

Telehealth options: Some follow-up appointments may be given through video consultations to eliminate transportation challenges.

Extended clinic hours: Offering appointments in the evening and on the weekends for people with different work schedules.

Community health workers: Assist patients in dealing with certain cultural or language barriers by hiring persons from the same community.

Patient education: Ensuring the patients understand the necessity of follow-up care and explaining anything in a simple matter if illustrations are needed.

Integrated care model: Having specialists attend particular consultations in primary care premises rather than requiring the patient to make another appointment (Grant et al., 2024).

Two specific programs in our area that support these efforts include

1.HealthConnect: A public service organization whose mission is to transport indigent patients to their medical appointments without charge. Eligibility is based on the income of the household and there is no other means of transport available.

2. Care Link:A program that allows clients to pay an appropriate amount based on their earnings for specialist appointments and medications. Enrolment targets include those who gross 200 percent or less of the federal poverty level.

3.Oregon Senior Health Insurance Benefits Assistant Program (SHIBA):  SHIBA.Oregon.gov

4. Care Connect: Here are some ways to send referrals: www.care-connect.us is website. Send an email to [email protected]. Send a fax to 410-254-3005 Phone number called: (410-254-3002 4).: For services in mental health: After going through recommendation and acceptance process, anyone who needs help will be able to join the program.

These strategies and resources also seek to meet some of the complex needs presented by chronic patient populations in the hope of enhancing overall health outcomes through consolidated and increased access.