Fragmentation of care: its causes and what we can do about it

Our healthcare system is fragmented and lacks an integral value chain. The solution lies in collaboration and an integrated care approach.

Mrs. Jansen, 65 years old, has diabetes and osteoporosis. She has several practitioners. All are competent, yet something is missing in her care. She herself does not seem to be a participant in the care process. There is no central coordination. Every health care provider asks the same questions. On one occasion she was prescribed medication that did not mix well with medication she was already receiving from another specialist. The general practitioner was not aware of this. We can describe the care surrounding Mrs. Jansen as fragmented. Her situation typifies that of many people with multiple complex conditions.

What is fragmented care?

Fragmented care occurs when different healthcare providers and/or healthcare organizations do not work well together. The lack of collaboration is caused by each healthcare provider working from their own silo. These silos are perpetuated by mismatched funding, laws and regulations, data management and training.Fragmentation in care

Health care or health care?

Medical science has done a lot of good. Diseases that were incurable, we can fight. The average life expectancy has increased considerably in recent centuries, partly due to medical science.

However, there is a downside. Medical science has also stimulated far-reaching specialisation, leading to a reductionist, disease-specific approach. In this approach, the human being is a collection of cells, organs and/or diseases. Disease means ‘dysfunction of the body’. Health care has thus become disease care: the ‘repairing’ of the body. The emergence of specialist care led to people focusing entirely on their own specialism and losing sight of the big picture.

Disease-specific specialization has led us to organize the needs of patients separately. Those with complex multiple problems must go through several care paths. Mrs. Jansen from the example is in a care process for diabetes and osteoporosis. So she has to go through two care paths and they are not always well aligned, as evidenced by what goes wrong. Mrs. Jansen’s practitioners focus on their own task within the care. Overarching questions such as “How does the patient experience his/her care?” and “Is there sufficient coordination?” are not sufficiently central to such an approach to care.

Causes of fragmented care

We distinguish five factors that cause fragmentation in healthcare:

1. Specialization.

  1. The medical model divides the body into parts in which different types of doctors specialize. This is not a problem if the patient only needs to call on one specialist. It’s different when people have to deal with multiple complex conditions. One has to deal with different specialists. Everyone focuses on their own task, the patient walks along several care paths that run parallel to each other, as it were. For the growing group of people with one or more chronic disorders, a more generalist approach is needed.

2. Lack of shared responsibility.

Who has ultimate responsibility for the patient’s overall care? Who has what role in the care process? This is not always clear to patients with complex multiple problems and their care providers. The result is that healthcare providers remain in their niche and work alongside each other.

3. Caregivers have little personal contact with colleagues outside the organization.

Patients with complex care issues have to deal with care providers from different organizations. Professionals usually only see colleagues from their own organization. In practice, the need to suddenly work with colleagues from outside often has a disruptive effect on care coordination. This stands in the way of good coordination of care for patients with complex multiple problems.

4. Additional time and effort is required for effective referral.

This time is generally not reimbursed.

5. Most healthcare professionals do not have a shared electronic health record or information infrastructure to effectively coordinate care.

This complicates the coordination between different specialties and/or organizations.

The consequences of fragmented care

Fragmented care can harm health. For example, prescribing different types of medication without coordination can lead to serious health risks. Studies show that the rate of adverse hospitalization for patients with poor care coordination is higher than for patients whose care is well coordinated.

Then there’s the cost. Research shows that fragmented care is twice as expensive as an integrated care approach. Largely, this is due to unnecessary testing and excessive use of medication, also known as polypharmacy.

The solution: cooperation

If parties are working at cross purposes, the most obvious solution seems to be better cooperation. Healthcare providers must work toward an integrated care approach. The patient must be central in this. All caregivers and others involved know his/her medical history, preferences and needs.

What are the basic elements for an integrated care approach? We can distinguish the following seven:

1. Integral financing. If we want to work together effectively, there must be an integral budget for all the care providers involved. This must be spent carefully and cooperation is indispensable for this.
2. A renewed corporate structure, with more collaboration and multidisciplinary teams.
3. A shared Electronic Patient Record (EHR). This gives healthcare providers access to the patient’s care history and enables them to coordinate their care with each other digitally.
4. Recognition and respect for those directly involved around the patient’s care: informal carers, family and friends.
5. A clear picture of the patient journey. How does the patient experience his/her ‘journey’ through care? We can find this out by means of questionnaires, the so-called PREMs. These provide a picture of where the patient experiences possible fragmentation.
6. Minimal disruption to the patient’s life. He/she should be able to continue his/her life as usual, arranging things around the care should not dominate.
7. Striving for health. A good life for the patient should be what healthcare providers strive for.

Preventing fragmentation of care: Download the free e-Book

As indicated, care is fragmented and there is still much to be gained in terms of cooperation. Download the free e-Book and read how to do this in practice.

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dr. Pim Valentijn

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