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Community Health Vital for Healthy People

Posted By Prucia Buscell, Thursday, August 28, 2014

Leana Wen, MD, an emergency physician who has worked in inner city hospitals in St. Louis, Boston and Washington, D.C., writes in her blog about the painful experience of administering short term fixes to patients whose long term afflictions lie beyond her realm.

She describes a 19-year-old who has come to the emergency room three times with cuts and broken bones and gunshot wounds. An 8-year-old without an inhaler living among relatives in an overcrowded house with lots of smokers comes to the emergency room struggling to breathe. A 38-year-old single mother diagnosed with cervical cancer four years ago never got to see a doctor as she struggled with three part time jobs, the care of four children and inadequate insurance. By the time Dr. Wen saw her in the emergency room, her cancer had spread to her lungs and intestines.

"We in the ER provide a necessary service, but it's far from being sufficient," she writes in her blog The Doctor is Listening. "We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime and poverty. An MRI here, a prescription there, these are Band-Aids not lasting solutions. Our communities need innovative approaches to issues like homelessness, drug addiction, obesity and lack of mental health services." The route to good health, Dr. Wen says, is in the community. Dr. Wen is coauthor of the book When Doctors Don't Listen.

When he was still writing the Wonkblog for the Washington Post, Ezra Klein described an experiment in Oregon to rebuild the state's Medicaid program around community health rather than individual fee for service treatments. Klein tells a story Oregon Gov. John Kitzhaber loves to tell. Kitzhaber, a former emergency room physician himself, calls it an illustration of what's wrong with our healthcare system. A 90-year-old woman with well-managed congestive heart failure lives in an apartment without air conditioning. When her apartment gets too hot, the strain on her cardiovascular system causes heart failure. Medicare will pay for an ambulance and $50,000 to stabilize her, but not $200 for a window air conditioner.

The 90-year-old may be hypothetical, but the story illuminates a common paradox, and Oregon's experimental approach starts with creation of 16 Coordinated Care Organizations (CCOs) that are responsible for assessing the health of their communities. Kitzhaber has given the CCOs flexibility on how they can spend Medicaid money. They can buy that air conditioner. An NPR story describes a Medicaid purchase of a minivan for community health workers who can be available around the clock to pregnant women trying to stop substance abuse, and to help mothers get to doctors' appointments, school and jobs. What makes CCOs different from accountable care organizations, or managed care, is the community component. Once they assess needs, they have to come up with ways to address them. So money can be spent on care coordination and community health workers with the aim of preventing some expensive emergency care. Gov. Kitzhaber told Klein, "We're investing in health. It's just a paradigm shift."

With thanks to Annette Garner, who teaches in the nursing program at the Health & Science University, Portland, Oregon.

Tags:  buscell  complexity matters  health  healthcare  medicine 

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