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Perfect Occupancy

Why everyone needs coordinated care

By JESSE BETHKE GOMEZ, MMA

The pandemic has helped us see more clearly the true scope of this platform, especially when considering older adults, people with disabilities and individuals with complex heath conditions. On one end, it includes health care institutions, i.e., hospitals, clinics, primary and behavioral health care, and on the other, home and community based services, also referred to as long term services and supports. We have the opportunity to elevate patient-centric care by integrating and creating continuity within this otherwise bifurcated health care platform, especially for people with disabilities, with complex health conditions and older adults in order to attain better health outcomes.

The Health Care Platform

Whether through the Home and Community Based Services from the Minnesota Department of Human Services or by other service delivery providers, the role of long term services and supports has become an integral part of the health care platform in order to maintain daily living for many older adults, people with complex care conditions and many people with disabilities.

In essence, this integrated model, which is an emerging standard for physicians and clinicians as a patient-centric practice, recognizes the necessity of continuity of primary and behavioral health care coordination, when needed, with long term services and supports. Furthermore, they must all work in tandem for the patient’s health, well-being and daily living. It is optimal to assure that scope of practice integrates these key areas of concern that are essential for a patient’s health, well being and daily living. To do so advances a much-needed interoperability of our health care platform.

Physicians are not usually involved in the county’s assessment process.

Coordinating Care

Ronna Linroth, PhD, worked with adults with disabilities for many years in a variety of settings. Dr. Linroth led the multidisciplinary team that developed a comprehensive rehabilitation clinic that offered coordinated services for adults with childhood onset conditions at Gillette Children’s Specialty Care in St. Paul, MN. Dr. Linroth’s Doctorate is in Applied Management and Decision Sciences with a focus on Leadership and Organizational Change. Dr. Linroth also holds a bachelor’s degree in Occupational Therapy and a master’s degree in Health and Human Services Administration. There is great need to coordinate care and assure the continuity of that care with a patient’s long term services and supports. Dr. Linroth, given her extensive career in health care and working with people with disabilities, offers profound insights on why this integrated model is greatly needed:

“The fragmentation of care for adults with disabilities is a primary barrier to supporting patients with disabilities. Unless an individual can see a physician specializing in the coordinated care of individuals with chronic care needs and familiar with the underlying childhood conditions or adult-acquired disabling conditions, the individual or family are the interpreters bearing information from the various subspecialists involved in their care.”

Dr. Linroth further elaborates: 

“The urologist addresses the urology needs, the orthopedist the orthopedic needs, the neurologist the neurology needs, the cardiologist the cardiology needs, etc., and may not see the review of the long term services and support systems as their area to address. Patients are often seeing a variety of specialists and the general practitioner, usually an internist or family practice physician, may not have the whole picture and may be the last on the list of appointments to make.”

Yet in order for this integrated and practical model to be scalable and sustainable, health care leaders, institutions, the insurance sector and policy makers need to provide for physicians and clinicians to evolve their practices and health care system delivery models in order to provide for the continuity of care coordination with long term services and supports for their patients.

Dr. Linroth speaks to workable ways to make this transition doable:

“Physicians have constraints on their clinical time, and documentation in an electronic record has become standardized in the industry. Currently, documentation formats are designed primarily to capture reimbursement for the majority of patients, but all are customizable to a degree. Building long term services and support reporting into the electronic record for people with disabilities would not only act as a trigger for review of targeted populations, but also provide an efficient format for capturing information needed by medical/rehabilitation team members, patients and payers.”

An integrated model also takes into account that the health and well-being of a patient changes with the aging process. Furthermore, specific disabilities, as well as complex health conditions, can also be progressive. There is no doubt that the continuity of primary health care, along with behavioral health care coordination and long term services and supports, need to adapt proscriptively in support of the patient as a result of aging, progressive conditions or both.

Integrating Perfect Occupancy

Minnesota’s health care platform is already arrayed along a continuum of primary care to behavioral care to long term services and supports. So, this is really about a concept applied from the productivity sciences by the work of my colleague Mr. Tor Dahl, chairman emeritus of the World Confederation of the Productivity Sciences and chairman of Tor Dahl & Associates, who introduced the term perfect occupancy, which is doing the right thing, in the right way, at the right time.

The importance of care coordination with long term services and supports are essential.

For this integrated health care model, we can apply the concept of perfect occupancy to our health care platform with the following definition:

“Put the patient in the driver’s seat for their health, well-being, safety and daily living, in which there is continuity of their primary and behavioral care coordination with their long term services and supports in real-time, all the time.“

Dr. Linroth elaborates on the need for primary health care, and when needed, behavioral health care, to take into account the effects of aging, progressive conditions and the integration with long term services and supports as a patient-centric modality.

Pain, changes in functional performance, need for assistive technology devices and services, status of personal care assistance, transportation and housing are areas to consider. Best practices in prevention or minimization of further disability due to overuse syndromes, age-related changes or progression of an underlying condition should guide the care visit and referral to the appropriate services in mental health, physical and occupational therapy, social work and other community supports. Primary care visits may fall to the wayside with the number of appointments the individual has with the rest of their medical team.

Physician Involvement

According the Minnesota Department of Human Services, the MnCHOICES Assessment uses a person-centered approach to gather information to assist an individual to make decisions about their long term services and supports. It assesses the person’s general health, their ability to take care of routine daily tasks and help the individual receives from family and friends. Once their assessment is complete, they will receive a community plan. The MnChoices Support Plan provides coordinated services and support plans for people who are eligible for publicly funded services. The coordinated services and support plan outlines the decisions the person makes for the services and supports they are eligible to receive.

I asked Dr. Linroth about the involvement of physicians when they are asked by their patients to be aware of their patients’ MnCHOICES assessment and subsequent support plans. Dr. Lithgow’s thoughts illuminate the value for the patient when the physician becomes involved:

“To my knowledge, physicians are not usually involved in the county’s assessment process, and unless their patient provides assessment results or their personal support plan, the physician would not be aware of either. The MnCHOICES Planning Assessment is meant to be conducted face-to-face with a certified assessor within 20 days of a request and follows a computerized program for information gathering.”

Linroth further states:

“The format is person-centered, giving the individual with disabilities (and older adults) to have their priorities identified. To promote standardization of the process, assessors are required to complete the training requirements, take and pass the MnCAT Setp3-Part 3 Test, as well as maintain their certification by documenting completion of 45 CEUs. Physicians and other paid service providers may be involved by sharing information in writing or by phone before and/or after the assessment if the individual requesting the assessment gives their permission to be involved.”

The importance of care coordination with long term services and supports are essential for the patient’s health, well-being and daily living. Elena Rosas, MD, is Medical Director and Adult Psychiatrist at Canvas Health in Oakdale, Minnesota. Dr. Rosas has worked at Canvas Health since 2010. She is board certified with the American Board of Psychiatry and Neurology. Dr. Rosas received her medical degree from the Medical School and Psychiatry Residency at the University of Minnesota.

Behavioral health is advancing the integration of dual diagnostic care for clients with co-occurring disorders. At the same time, behavioral health is making gains in care coordination with primary health care in addressing the health and well-being of clients. Dr Rosas elaborates on the awareness and importance of continuity of care coordination with long term services and supports for patients:

“As a psychiatrist who has worked in community mental health for the past 16 years, the awareness of and coordination with a patient’s long term services and supports are essential. It is wonderful when patients with significant disabilities are able to access additional support services in their lives, such as housekeeping, personal care assistant services, and home health nursing support. To have this type of help can make all the difference in the world to the patient’s quality of life and overall health management.”

An Emerging Standard

In essence, this integrated model, which is an emerging standard for physicians and clinicians as a patient-centric practice, recognizes the necessity of continuity of primary health behavioral health coordination, when needed, with long term services and supports. Furthermore, they must all work in tandem for the patient’s health, well-being, and daily living. It is optimal to assure that scope of practice integrates these key areas of concern that are essential to a patient’s health, well-being and daily living. To do so advances a much-needed interoperability of our health care platform.

Dr. Rosas offers a profound example on why this model needs to become standardized throughout the health care system in the United States:

“In my experience, the very best care of the patient occurs when all services involved are coordinating with each other. I recently had a patient who gets confused often due to a persistent mental health condition. She was struggling with daily living, such as attending medical appointments. My agency, Canvas Health, became a Certified Community Behavioral Health Center earlier this year, and as part of this dedication to comprehensive care, we have established a new program called Care Coordination. We were able to assign a care coordinator to this patient, who reached out and coordinated with all of the members of her team to have everyone work together to assist this patient to make it into the office to get the care she needed. Care coordination has made a positive difference for the patient. I am quite confident and hopeful for the future of community mental health care, if we as a health care system can increasingly prioritize and value this integrated model of continuity of care coordination with all services for the benefit of the patient, we will evidence better health outcomes in the United States.”

Jesse Bethke Gomez, MMA, is the executive director of the Metropolitan Center for Independent Living. Jesse is a thought leader on complex health care, human service and public health policy issues driving societal progress. He is a National Kellogg Fellow in Public Health at the University of North Carolina.