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Sample Paper: Nursing_Assignemnt_-_Fragmentation_of_Care,_Care_Coordination_and_Challenges.doc


United States’ health care is often described as being fragmented. Fragmentation spans across all levels of health care, from the national level to the outpatient clinics and also within confined system care. Fragmentation has been cited as one contributor towards the poor state of the nation’s health care. This has led to several effects resulting from fragmentation gaining permanency within the health care system. One of the effects is the exponentially increasing number of patients who visit different healthcare settings and their needs are not met. This has resulted to a trend of worry and frustration. The collapse of communication has made accountability difficult. Unaccountability and ambiguity in assessment of quality is harmonious to increased medical errors and duplication. It also implies that the costs of health care are in an exponential upward ascendancy. In this regard, it is fundamental to realize that fragmentation affects both financing and health care provision.


This paper will lay focus on healthcare provision. It is instrumental to review the existing care coordination models and assess how well they counter the key problems brought about by fragmentation of care in community health centers. Community health centers are designed to serve a populace with limited income and/or education, and are faced by language and cultural barriers. They also serve several uninsured people. These elements aggravate the problems caused by fragmentation and decrease quality of care. The paper will review the available knowledge on care coordination models and challenges that a primary care provider encounters. It will assist in the conceptualization of a customized model that targets intrinsic problems of fragmentation.


Fragmentation in health care can be defined as the aspect of having multiple decision makers in making decisions that involve health care (Michael, 2004). This means that fragmentation views individual decision making as incapable of screening all the dimensions of the decisions that need to be made. The individual decision makers are responsible for only one fragment of health care and may lack the power to take all the necessary action given that they know information regarding their fragment only. Fragmentation can also be defined as a concept that brings inputs together, delivery administration and association of services in relation to diagnosis, treatment, care, remedy and health promotion. Fragmentation is a means that aims improving service delivery in regards to accessibility, quality and patient satisfaction but so far it has failed in doing so.

Fragmentation can take several dimensions when it comes to health care provision. One of the narrowest dimensions could be fragmentation in treatment of a certain illness during a single stay in a hospital. There could be a lack of coordination between nurses which could lead to misunderstandings. For example, a patient could inform one nurse that he/she is allergic to a particular kind of medication. If the nurse fails to inform the nurse in the next shift, the latter will give that particular medication to the patient. A broader conceptualization of fragmentation may come into play on fragmentation in treatments for a patient at a given time, such as lack of coordination between the health care providers he/she visits. For example, a surgeon could use a high-sugar intravenous injection on a diabetic patient if he/she did not consult with the diabetic specialist treating that patient. Additionally, fragmentation could be worried about if an insurer underfunds preventive care just because Medicare will bear the responsibility later.

Care coordination is a term that can be used interchangeably with case management, disease management and care management (Fero, 2011). There are several variations of care coordination. All the variations intend to improve care, reduce unnecessary service utilization and promote independence. Coordination occurs along a scale from social to medical in a range of settings that embrace independent care coordination organizations, provider organizations, health systems, integrated networks and group practices. Care coordination models include social models, medically oriented models and integrated models. Social models address and authorize residential, institutional and in-home care services. Medically oriented models coordinate medical treatments for high-cost receivers, pharmacy management and disease management. Integrated models bridge the medical and social models. There is professional agreement on the constituents of most care management models but implementations of the models vary considerably. These variations arise due the location from which the case management is presented. The case managers, purpose of the services and level of authority also affect case variability of case management.

Care co-ordination has been identified as a key priority for quality in health care provision. Many organizations such as Centers for Medical and Medicaid Services (CMS), Commonwealth Fund, the National Quality Forum and the World health Organization (WHO) have acknowledged this as a key component that should be observed in delivery of health care. Gaps in care provision have been viewed to contribute towards costs, unnecessary and/or duplicate tests, contribution to errors, and delayed diagnosis. These factors jeopardize the safety and satisfaction of patients. They also impact negatively on efficacy and efficiency of health care provision. Both the private and public sectors have been recently involved in trying to minimize the challenges caused by these barriers. Alignment of quality and coordination of care with cost has been suggested through a new payment and service delivery policy by Accountable Care Organizations. Care coordination is centered on patient care, with the input of all clinicians (physicians, nurses, RNs, pharmacists, social workers, therapists) all working in harmony for the best outcomes on the patient. They need to organize and coordinate better care for a patient. There are four key ingredients that contribute towards successful health care provision. These are sharing of information within the care infrastructure, collaboration between team members, and provision of support in decision making and personalization of experience for the patient and care provider.

Institute for Healthcare Improvement came up with a care coordination model that aims at better care for people with multiple health and social needs at lower costs. IHI is a private non-profit institute working in concurrence with health care providers. Firstly, IHI identified individuals with multiple health and social needs as being among the highest consumers of health care services. This means that they are drivers of high costs in heath care. These elevated costs aids in understanding the needs and priorities of these people and this can be used to invent a plan that caters for their needs at lowest possible costs. Health care in the United States is disproportionate to a vast extent. Chronic conditions consume highly on health care since chronic conditions are expensive in remedying. The Triple Aim IHI initiative unearthed that people with chronic health conditions suffer multiple illnesses and undergo several social complexities. They are, therefore, least poised to go past the challenges of complexity and fragmentation of health care systems. They act only as links between different health care providers. Care givers may identify the social needs of these individuals but also recognize the incapability of the system in meeting these needs. As suggested, care coordination should deliver health benefits to individuals with multiple needs, and also improve their experience of the care system. The IHI care model takes into consideration identification and intervention of an individual’s property to generate a customized plan for these people. IHI model appreciates that care coordination is a mechanism of assessment of care plan effectiveness and making of adjustments to avoid delivery of care in exceptionally expensive environments. In working out the care coordination model, the IHI Triple Aim workgroup first focused on the homeless populace. The group discovered that frequent visits to hospital for health care were an indication of failures of the housing system in meeting the needs of this population. Homeless people face a crisis in countering chronic diseases and frequently struggle with addictions and/or needs in mental health care. These patients would find a haven in a well coordinated, holistic medical home rather than an emergency room. Under the model, the Permanent Supportive Housing tries to solve the burden of homelessness.

The model can be illustrated as in the figure below.
Goals Coordination Patient Value Service Service Outcome Identification proposition design delivery Feedback Feedback The key elements of IHI care Coordination Model are individual and family assets, patient identification and the care coordinator. Individual assets comprise of the resources, gifts and strengths of an individual. This set of resources and strengths can be leveraged to improve the health of the above mentioned group of people. Assets were found to be an overlay of the whole coordination process. Patient identification seeks to pick out the people who would benefit maximally from care coordination services. It seeks to identify the populace that is failed by primary care. Identification is primarily through a scan of the most frequent hospital users. Other innovative predicative ways can be used to identify persons who are poised to drive high health care costs in the future. It could be through assessment of ambulatory sensitive admissions. The care coordinator is the person responsible for identification of individuals’ health goals and coordinates services to meet these goals. The care provider could be a nurse, social worker, community health worker or just a lay person. He/she ensures that the care plan is implemented in partnership with the individual at the center of the plan. He/she ensures that the plan is delivered as depicted. He monitors the feedback loops by monitoring proper working of the service design and coordination.

The care coordinator has a task in the value proposition, service design and service delivery.

Another model was designed by MacColl Institute for Healthcare Innovation. The model can be summarized as in the figure below.
-Providers get the information they need Relationships & Agreements when in the need of it. Connectivity -Practice is aware of the status of all referral -Patients report receiving assistance in Coordinating care. Two other models are evidence of care coordination interventions. These are transitional care models which aim at reducing hospitalization and readmissions. Readmissions within short intervals are a key challenge to people who suffer chronic illnesses. 18% of hospitalized Medicare patients are readmitted within a month from the time they are discharged. These readmissions often occur because these patients do not understand how to take their medication properly. Transitional care models are interventions that are devoted on preparation of patients for transition from the hospital setting to home. One of these models was developed by Naylor et al in 2004 for patients hospitalized with coronary heart failure. It made use of advance practice nurses who met with patients in hospital and at home immediately after their discharge. The APNs provided passionate education on use of medication, self-care and identification of symptoms. Follow up on these patients after one year revealed that the rehospitalization rate had fallen by up to 10%. Coleman et al in 2006 developed an almost similar model but this one targeted hospitalized patients with chronic diseases. The model uses APNs who provide patients with tools to promote communication, encourage patients to take active roles in their care, and also provide continuity of care and guidance. Rehospitalization rates fell by up to 20% among those who had undergone through the trial model.

All the models discussed above aim at addressing the problems brought about by fragmentation. Each model aims at improving one or more of the element (accountability, patient support, relationships and agreements and connectivity). The models address accountability through the development of a quality improvement plan and designing clinic’s infrastructure, which address decision making and tracking system of referrals respectively. Patient support is addressed organizing support teams for patients and their families. This is achieved through delegation of the duties to APNs. It is also done through assessment of patient’s clinical, logistical and insurance needs. Follow ups are also provided in most models for post referral or transition patients. Relationships are addressed through identification and maintenance of rapport among key specialty groups, community agencies and hospitals. Connectivity is maintained through development and implementation of transfer systems such as e-referral system.

Community health centers face several challenges, which are brought about by fragmentation of care. The health centers usually cater for outpatient case. In regards to this, they face a challenge of short term insurances. This is because Medicare is perceived to be responsible for insuring these facilities. They also cater for patients many of whom do not have any insurance cover. Many community health centers do preventive care, which is underfunded by insurers leaving Medicare to assume the responsibility (Havens, 2006). These health centers also face a challenge in efficient and adequate management of chronic diseases. Often, people with multiple health and social needs require attention from these centers. Fragmentation has led to clinicians working within confined “silos” which have made referrals networks large and depersonalized. Doctors are likely to with hold crucial medical information from other doctors or nurses. This could result in inappropriate treatment of conditions or administration of medication which otherwise is detrimental to the patient. The aspects of fragmentation also cause this group of people to take time in seeking supportive services, which could lead to exacerbation of their conditions. This crisis could have been avoided if care was well coordinated, which could make accessibility of the services more reliable. Numbers of chronic conditions that require ambulatory services of which primary outpatient care would have sorted are poorly provided in community health centre. Hospitalization and rehospitalization increases dramatically with each additional condition (Shelton, 2004). Fragmentation has made it difficult for people to negotiate complicated systems of delivery in community health center. Arrangement of schedule services, communication and monitoring are also affected by fragmentation (Chesnay, 2005)s. Without proper integration of care coordination, quality of care remains low in these centers because of the effects of fragmentation. Care provision is also affected by language barriers in these health centers. Many of the people who need who visit community health centers have multiple health and social needs. In North Carolina, residents of Hispanic descent have protested against having to wait long hours before they are being served than their non-Hispanic counterparts (Shi, 2011). This is because the health system lacks qualified translators. Translations are done by family members or unqualified department workers. This is one aspect of fragmentation that has led to poor service delivery. There is little linguistic access provision in a state like North Carolina. Health providers in community health centers have little knowledge on linguistically accessible health service. It is the duty of medical provider associations to educate the health workers about this. However, because of fragmentation in care provision, few milestones have been achieved in regards to this. Community health centers have been unable to provide linguistically and culturally apposite services and outreach. These health centers also have inadequate educational resources for provision health care. Educational resources include tools for tracking and updating lists of community resources, eligibility criteria and capacity of programs (Gofin, 2010). They have inadequate staffing in nurses with clinical experience who would have been more appropriate for care coordination. In spite of credential of background, care coordinators should have appropriate training and tools to enable them document client information.

A visionary look at care coordination would address all aspects of any care model. Incorporation of technology would be fundamental in care coordination (Nixon, 2011). Information sharing between different care givers would reduce the time wasted in diagnosing medical conditions. Use of technology would ensure collaboration thus in proper care coordination would require each clinician to acquire skills in information technology. This will in turn increase the time that is spent by the patient with the doctors in the treatment. Provision of clinical skills is also instrumental in increasing time spent between patient and clinician. A new model would require clinicians to develop new clinical skills, which would be provided in medical and nursing schools. New models should also incorporate proper tracking mechanisms of referrals (Umer, 2010). Referral tracking is made easy by information systems that record the processes of referrals. This would increase the time spent between a doctor and his/her patient since no time will be wasted in trying to find medical records. In addressing patient support, referral coordinators should identify and attempt to resolve all the logistical and financial barriers in completing the referral. Timely appointments would also be a key to increasing time spent between the patient and the doctor. Transfer of clinical information would also assist in increasing time spent with clinicians since no time would be wasted in trying to find records and new medical records of the patient. New models would also address the issue of caseload in many community health centers. Many community health centers are poorly funded. As a result, they end up having inadequate staffing. This means that each clinician has a greater work load and thus poor service delivery. It also implies that the clinicians will not be thorough in attending to patients. This model would provide training to the untrained workers to help in care provision especially for those conditions that require ambulatory services. A model that takes a holistic approach to care coordination would be appropriate for dealing with chronic conditions. Recovery of patients with chronic conditions demands focus from their family, as well as from the primary care provider. Care givers should be screened thoroughly for conditions such as depression, basing on the understanding that depression of the care giver puts the patient at a risk of neglect. The effective roles of a primary care giver should not be interrupted by such conditions. Therefore, health systems should come up with ways of reducing such cases.

Fragmentation has been detrimental to care provision. Care coordination is, however, countering the effects of fragmentation. Care coordination models have been designed with an aim to improve care for people with multiple health and social needs. The models have been tested and applied especially in community health centers. Community heath centers are faced by a wide range of constraints arising because of care fragmentation. However, with appropriate care models, the challenges can be avoided.


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Gofin, J. (2010). Essentials of global community health. Sudbury, Mass: Jones and Barlett Learning.
Institute of Medicine Committee. (2011). The future of nursing: leading change, advancing health. Washington, D.C: National Academics Press.
Nixon, B. (2007). Care coordination and the way forward. Chicago: University of Chicago Press. Havens, E. (2006). Affordable health insurance in America: secrets and tips to help you in your search for medical coverage. New York: Universe
Judith, M. (1998). Medicare preparing for the challenges of the 21st century. Washington, D.C: Distributed worldwide by Brookings Institution Press.
Chesnay, M. (2005). Caring for the vulnerable: perspective in nursing theory, practice and research. Sudbury, Mass: Jones and Bartlett.
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Shelton, P. (2011). Comprehensive care coordination for chronically ill adults. Chichester, West Sussex: Wiley-Blackwell.
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Umer, C and Bruno, M. (2010). Future directions for the national healthcare quality and disparities reports. Washington, D.C: National Academics Press.
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