Reference no: EM133662508

Problem

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"Wagner explains that successful chronic disease intervention involves a coordinated multidisciplinary team, consisting of physicians, nurse case managers, pharmacists, social workers and community health workers (2000). According to Wagner, patient care teams have the potential to improve health outcomes and decrease health care costs (2000). Some patients with multiple chronic diseases have a family doctor, as well as several specialists, each with their own care teams. I agree that patient care teams have great potential to provide safe, holistic care. Unfortunately, this seems to be easier in theory than in practice. The key word in Wagner's chronic disease management model is that successful chronic disease intervention involves a coordinated multidisciplinary team. But in instances with multiple care teams, who is supposed to coordinate this care?

Acting as a gateway to services, family doctors often provide referrals to specialists for consultation and follow up. Unfortunately, due to health care shortages, many Canadians do not have the privilege of being connected to a family physician. In 2019 approximately 4.5 million Canadians did not have regular access to a family doctor or nurse practitioner (Tasker, 2024). Within the past few years, this problem has only worsened. In 2023 it was estimated that 6.5 million Canadians were without primary care access (Tasker, 2024).

In addition, the historical lack of communication between primary care and hospitals is an "ongoing source of difficulty for patients and irritation for providers" (Martin, 2017). As Martin describes in her novel, the lack of communication between primary care and hospitals can certainly lead to negative health outcomes (2017). Martin provided the example of an elderly patient who was living independently in the community (2017). This patient had multiple chronic diseases. During an exacerbation of her symptoms, she attempted to schedule an appointment with her family doctor. Unfortunately, her family doctor was away and did not have another physician to cover them. With nowhere else to turn, she accessed her local emergency department and was then admitted to hospital. During admission, her medications were changed, her symptoms stabilized and then she was discharged back home. For one reason or another, the hospital did not inform the patient's primary care provider of this admission or the changes in her medications. Then the patient suffered from a life threatening medical injury because of her lack of medical follow up, post admission.

Through this example, Martin highlights that the breakdown of communication and coordination between the hospital and primary care providers can lead to significantly negative health outcomes, which rob people of their health and well-being as well as their ability to function independently (2017).

Unfortunately, these events happen more often than not. It is clear that with coordinated and timely multidisciplinary communication, negative outcomes can certainly be prevented, thus allowing Canadians with multiple chronic diseases to live independently as long as possible.

This leads us to ask, what are the barriers to effective and efficient communication between acute care teams and community care teams? And how can we reduce or overcome these barriers? Also, knowing that hospitals are often very busy with emergencies and acute care, how can we engage hospital staff to participate in processes aimed at improving timely discharge planning and safe transitions back to their community providers?"