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Integrating Head and Neck Services - An evolution towards patient centric care.
ENT/Head and Neck services are delivered independently and seldom as a team in most medical centres across India. Although the standard of medical and surgical Head and Neck care in most centres is nearly similar
to our western counterparts, the care given is often fragmented and with a great degree of variability in access and availability of subspecialisation. Furthermore, smaller hospitals often offer care delivered by a single surgeon. Thus, fragmented care, poorer outcomes and patient dissatisfaction are a common problem. ENT as a specialty developed leaps and bounds often needing collaboration and cooperation between specialty. It is time to broaden horizon and integrate Services as a multidisciplinary model to deliver seamless quality care. I would like to share our own learning experience in developing such model in a secondary care hospital
Integrating head and neck services(IHANS) under one roof seamlessly was one of our mottos. Clinical evidence from other integrated health care systems like Mayo Clinic, Freeman Hospital and Cleveland clinic has shown that this has certainly enhanced patient care and patient experience in a significant way with far better patient outcomes.
How is Integrated Head and Neck care delivered?
· Multidisciplinary care team (MDT) - A multidisciplinary patient care team is composed of a group of professionals who communicate with each other regularly about the care of a defined group of patients and actively participate in that care. This is the essence of the integrated care pathway. The expectations of the patient and the complex nature of treatments has led to the development of multidisciplinary teams. This is the standard of care in the western world. Evidence from medical literature has shown that patient related outcomes are better with MDT care. This is more so in head and neck cancer care, management of sleep apnoea, facial trauma, paediatric airway disorders and skull base tumours. Over the last four years adapting such models has shown to be successful in complex and inter-disciplinary areas and has reinforced our belief in such models of care.
Examples of Multidisciplinary teams @ PTH
· Integrated clinical pathway - integrated care pathways are structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem, and describe the patient’s expected clinical course. Clinical pathways should be derived from evidence-based guidelines and translated into practice. The pathways now adapted at People Tree hospitals are based on clinical best practices around the word. One of the important benefits of using clinical pathways is to improve patient experience throughout their journey in the hospital & thus deliver high quality care. The role of an individual should be predefined so each one knows their role
· Feedback, reminders, and education for professionals - The aim of feedback, reminders, and education is to provide health care consumers with information regarding appropriate care for patients. Patients need consistent feedback and constant reminders about medications and life style changes. Medical and Paramedical staff like speech therapists and dieticians constantly remind patients of do’s and don’ts and lifestyle modifications. Further development of nurse specialists like wound care nurse and diabetic nurse have led to more consistent results and has increased patient compliance. Patient education days, disease awareness weeks, lifestyle connect programmes have helped us to connect with certain group of patients directly.
· Self-management support and patient education
Education about illness, benefits and limitations of treatment are important tenets of patient directed education. Disease related leaflets, (For eg vertigo rehabilitation exercises, migraine avoidance, voice care, diet, reinforcing surgical consents with leaflets and videos) and disease specific awareness about some of the long-term illness and long term care, are given to patients and to their attendants. Programs such as ‘Lifestyle Connect and Health talks’ on public forums are unique programmes in People Tree Hospitals that have led to more patient compliance with self-care, disease awareness and medication use in long term illnesses. Patients often need to take ownership of their illnesses understand strength and limitations of modern evidenced base medicine.
Lifestyle diseases like obesity, Head and neck cancer and sleep apnoea need a lot of self-management and motivation which can be achieved from increased awareness. Patients who are on long term tracheostomy care often need collaborative care from both paramedical staff and their own kith and kin, particularly in the community. Training in tracheostomy care by doctors and nurses, often helps the patient and attendants acquire the skills and knowledge to manage their own illness. The hospital helps in long term self-management and routinely assesses problems and accomplishments.
· Follow up - Close follow up and monitoring the patient during or after treatment is paramount. This is more so when we are expecting a serious diagnosis (for eg cancer) or after complex surgical or medical treatment. Some patients need stringent postoperative care and regular follow up. A hotline to reach the emergency room either by ambulance or opportunity to connect with the staff is provided for easy access and continued care. We foresee the development of Head and Neck specific nurse specialist for patients to liaise with directly either by phone, mailings, or visits.
· Case management - Some treatments in the Head and Neck region are inherently more complex, time consuming and multidisciplinary. Patients often get lost in the system because of a multitude of reasons. We see many patients coming to the hospital from far and wide, often needing a helping hand to take them through the system. The provision of a case management team or allocation of the patient to a social worker is often needed. The case manager or team takes responsibility for guiding the patient through the complex care process in the most efficient, effective, and acceptable way. We have adapted this in our orthopaedics department effectively & are working on developing a robust pathway in the head and neck.
You treat a disease: you win, you lose
You treat a person, I guarantee you win-no matter the outcome..
-Patch Adams
· Developing a culture to improve and maintain quality of care - We are setting up protocols to make the hospital system NABH compliant. This will certainly improve the standard and consistency in care provided. Audits, stringent infection control practices, constant & ongoing nurse and doctor training & education, robust clinical governance policies and constant evaluation of our practices based on patient feedback has helped us to continue to maintain and improve the quality of care provided.
Pursuing integration: What needs doing?
· Offer advanced capabilities - Advanced clinical capabilities are offered in the form of physician expertise and technology. Medicine is rapidly advancing and technology driven. Subspecialty interest is the norm in most advanced centers. Bringing advanced technologies under one roof (Lasers/robotics, etc), developing a ‘hub and spoke’ model and spreading awareness among consumers about the benefits of such technologies will be the next focal point.
· Consistency in quality of care delivered - Advanced clinical capability carries with it an expectation of higher quality outcomes. Collection of data and developing robust recording and analysing systems helps to constantly compare, adapt and change when and where necessary. Currently People Tree Hospitals have a network and a system to electronically record clinical events; the progress to embrace this system by doctors and paramedical staff has been a slowly ongoing process. Monthly audit, Integrated clinical governance meetings, patient feedback systems and implementation of NABH standards at every hospital will bring in consistency and constant evaluation of practices.
· Standardize care processes and management. The key to quality and affordability is driving out variation wherever possible. Quality of care and quality of management both rely on standardization of process at all the sites. This has been a challenge and robust process and systems are the need of the hour across the hospital systems with protocols and best practice guidelines.
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· Develop partnerships of trust with physicians. There is absolutely no way to effectively manage the quality, access and cost of care without physicians’ active and committed involvement. Creating partnerships with local and distant medical community help to develop continuity of care for the patient.
Close collaboration, timely help and mentoring the referring doctors would be the future of vertically integrating medical care with the community & the primary care physician.
· Creating partnership with Governmental and Non-governmental agencies. Health care is the birth right of every citizen and access to quality health care is mandatory. Unfortunately cost of health care delivery has significantly increased over the years and becoming inaccessible to many. As the first step IHANS has partnered with People Tree Foundation to carry out some of the elective surgeries for the needy, free of cost or at a significantly reduced cost. Further partnerships with government programmes like Yeshaswini and Face Foundation has helped to carry out certain surgeries with reduced costs.
Conclusion: The ultimate benefit of an integrated system is its ability to deliver high value health care. This would mean better perceived outcomes, quality service, safe environment, health care at affordable cost and coordinated, holistic care for the patient.
References
1. Quality Of Integrated Care For Patients With Head And Neck Cancer: Development And Measurement Of Clinical Indicators
M. M. T. J. Ouwens, MSc,1 Henri A. M. Marres, MD, PhD,2 Rosella R. P. Hermens, PhD,1 Marlies M. E. Hulscher, PhD,1 Frank J. A. van den Hoogen, MD, PhD,2 Richard P. Grol, PhD,1 Hub C. H. Wollersheim, MD, PhD1
2. Integrated care programmes for chronically ill patients: a review of systematic reviews Marielle Ouwens, Hub Wollersheim, Rosella Hermens, Marlies Hulscher And Richard Grol
3. http://www.londoncancer.org/media/67668/ap-2b-head-and-neck-service-specification-240413-final.pdf
4. http://www.mayo.edu/pmts/mc4200-mc4299/mc4270.pdf
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