Officials of the state Medicaid program can be involved as stakeholders in supporting the project and its implementation in order to integrate and generate profit. Insurance organizations, businesses, and individuals who will make the financing decision and participate in the implementation can also be considered key audience members.
The US healthcare system
As patient needs change, the US healthcare system remains relatively unchanged. The episodes of seeking help and providing it are relatively infrequent and high in severity. It is necessary to transform the system aimed at patient care and change the models of care. Chronic disease management and prevention strategies require more frequent visits with lower intensity (Nash, 2016). It is important to provide continuum care aimed at coordination, the essence of which is maintaining constant contact with patients throughout their lives, not only during illness. It is critical to consider the aging population, the growing prevalence of chronic diseases, the trend towards shorter hospital stays, and the development of social security.
The concept of continuum care
The transition to a new model of care is a way to overcome the fragmentation of care and provide continuum care for patients. The Affordable Care Act (ACA) helps focus attention on chronic disease and public health, there are two models: Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH). The concept of continuum care, which includes an integrated approach to medical services, covers all intensity levels and represents a more advanced system that is most relevant to our reality and will be considered in work.
The correct process of transferring a patient and continuing to care for him/her can improve the quality of care and affect patients’ quality of life. It can help to avoid unnecessary hospitalizations in the future and reduce the cost of care. Nurses are responsible for ensuring that patients return home safely and receive the support they need, fostering better coordination and communication between professionals, patients, caregivers, and healthcare providers, and ensuring continuum care through successful strategies.
Often overwhelmed, nurses only provide transfer information to the patient during routine care activities, sometimes hastily and for a short period, trying to give too much information at one time. In addition, high patient turnover makes it difficult to share information about home care at the time of discharge. Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH) can play an active role in health care transition. The system can be changed through coordination, providing health education support and guidance on disease prevention, control and strengthening, and health maintenance to improve hospital discharge and ensure continuity of home health care.
The solution to the problem for the elderly or disabled can replace the usual stay in the hospital since it is possible to provide full assistance at home. In addition, special courses will be held for relatives caring for their elders or people with disabilities. The long-term care system helps older people get adequate care and live with families without resorting to nursing homes. Care for the elderly and sick people can also be carried out with the involvement of social workers.
The peculiarity of this format is that now help will be focused on a specific person and his needs. As a solution, it is also possible to create an individual package of services for each ward and revise its composition annually. When determining the optimal conditions for the provision of a social package, employees of social protection authorities will prioritize maintaining a citizen’s stay in a familiar favorable environment and take into account circumstances that worsen or may worsen the conditions of his life.
The key difference between the program to improve the quality of medical services is the transition from the declarative to the revealing format. If earlier a person himself or through relatives had to declare that he needs the help of a social worker, now social service employees must identify people in need themselves. Local therapists, doctors in hospitals, neighbors, and acquaintances can contact the social service and tell about a lonely elderly person. After that, the specialists will engage in diagnostics and decide on the inclusion of the citizen in the long-term care program.
Community health needs intervention
Community health is an area of health and clinical science research that focuses on maintaining, protecting, and improving the health of populations and communities. Community health interventions can be divided into primary care, secondary care, and tertiary care, where each stage focuses on a different level and approach to a community or population group. Primary health care (PHC) meets most of a person’s health needs throughout his life; it is people-centered, not disease-centered. Primary health care is a community-wide approach that includes health promotion, disease prevention, treatment, rehabilitation, and palliative care.
The primary health care approach has three components:
- meeting the health needs of people throughout their lives;
- addressing the broader health determinants through multisectoral policies and actions;
- enabling individuals, families, and communities to take care of their health.
By providing community care and community care, PHC addresses individual and family health needs, the broader public health concern, and the needs of specific populations.
Secondary care means that the doctor has referred the care to someone with more specific knowledge of any health problem you face. Specialists can focus on a specific disease, condition, or body system. If a person is hospitalized and needs a higher level of specialized care, the doctor may refer one to tertiary care. Tertiary health care requires highly specialized equipment and specialized knowledge. The PCP should remain involved when receiving tertiary care for certain chronic conditions, such as diabetes and chronic kidney disease (Asch & Werner, 2010). This is because he or she can help develop and maintain a long-term management plan.
Approaches to community health
Considering various approaches to community health, several can be distinguished in the scientific literature. The social pathway model takes a nomothetic position, seeking to determine how a small set of social factors affect the health of a community. In this model, the community is also considered as a dependent or grouping variable. The next approach, which views the community as a context model, has remained popular over time. It considers the context of a community as an independent variable, separate from the contribution of various other social factors – income, educational level, and family health behavior (Beatty et al., 2015).
This approach to the study of communities is a top-down model. The third model is the newest but least practical, treating the community as a complex system and taking a bottom-up modeling approach. The limitations of the first two models are problems that an integrated scientific approach to communities can deal with. It can deal with these problems because this third approach looks at communities holistically as systems. It sees the connection between micro and macro, has tools for studying emergent behavior at the system level, and can determine how environmental factors and the larger systems in which communities are located affect their health. His bottom-up approach also allows communities to be viewed as independent and dependent variables. It allows viewing communities as contextual and composite. It does not create a false dichotomy between community and other social factors such as income, education, and more.
The model adopted in the United States is characterized by the provision of medical care mainly at the consumer’s expense of medical services and the absence of a unified state health insurance system. The main instrument for meeting the needs for medical services is the medical services market. The part of the needs that are not met by the market, these are low-income strata of the population, pensioners, and the unemployed is assumed by the state through the development and financing of public health care programs.
The backbone of a healthcare organization is the private healthcare market, augmented by government programs for the poor Medicaid and Medicare retirees. Thus, funding for medical interventions is provided by individuals, commercial insurance organizations, and the state to a lesser extent.
Financial reimbursement strategies
Public health reform efforts are increasingly focusing on providing comprehensive and well-coordinated care for people with serious illnesses to improve the quality of care and reduce costs. The shift from treatment to prevention can be an important component of financial reimbursement strategies, backed by research showing that it increases patient satisfaction and reduces costs for people with serious illnesses (Kuhn & Lehn, 2015). Due to the paradigm, PCMHs and ACOs seem to be the most effective strategies to improve public health, reduce costs and improve patient care.
Accountable Care Organizations (ACO) are networks of health care providers that work together to deliver better, more cost-effective care to patients. These organizations were created under the Medicare General Savings Program, part of the Affordable Care Act (ACA) of 2010. These organizations were created to support Medicare members but now also include private payer networks.
The Patient-Centered Medical Center (PCMH) has been proposed as a practical solution to the primary care crisis and promises to provide the best continuum care. These are coordination, quality, the safety of service, orientation to all persons, personal doctor, doctor’s guidance, expanded access, and payment. PCMH can be seen as transitioning from treatment to prevention, made possible by continuum care.
The ACO and PCMH models
The goals of the ACO and PCMH models are similar, but the means to achieve the goals are different. According to CMS, ACO is primarily a value-based cost recovery model that involves “voluntary” collaboration between providers (Patel et al., 2020). At the same time, PCMH is primarily a healthcare delivery model that involves significant collaboration through the certification process. In other words, ACO can also be characterized as an incentive-based payment model that removes the errors of the payment-for-service model and makes providers accountable for results by providing them with a share of the savings earned. PCMH is a systematic approach that creates structures and processes to provide holistic and coordinated patient care.
The healthcare system needs effective transformation from different points of view. It may occur due to a change in the usual patterns of care for continuum care, which is possible in connection with the transition of the entire system from treatment to prevention. Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH) can transform the system and adjust it to our reality; considering community health needs and financial reimbursement strategies, this is the future of healthcare.
Asch, D. A., & Werner, R. M. (2010). Paying for performance in population health: Lessons from health care settings. Preventing Chronic Disease, 7(5), A98.
Beatty, K. E., Wilson, K. D., Ciecior, A., & Stringer, L. (2015). Collaboration among Missouri nonprofit hospitals and local health departments: Content analysis of community health needs assessments. American Journal of Public Health, 105, S337–S344.
Kuhn, B., & Lehn, C. (2015). Value-based reimbursement: The banner health network experience. Frontiers of Health Services Management, 32(2), 17–31.
Nash, D. B., Fabius, R. J., Skoufalos, A., & Clarke, J. L. (2016). Population health: Creating a culture of wellness (2nd ed.). Jones & Bartlett Learning.
Patel, P. M., Vaidya, V., & Gupte, R. (2020). Accountable Care Organizations and Patient-Centered Medical Homes: Health Expenditures and Health Services Utilization. The American Journal of Accountable Care, 8(2), 14-21.