Integrating Acute and Chronic Care (1999)

Ah, these issues of GenSrations are such a treat! The Gen Editorial Board selects a topic that is both important enough and murky enough to warrant closer scrutiny The topic at hand - the integration of acute and - certainly meets both those criteria. Then the board bestows an honor on an individual or two - this issue it is my turn, and I am indeed honored - and asks them to assemble a group of experts to examine the topic with the hope of moving our field forward. CLARIFICATION OF TERMS The first thing this panel of expert authors did was to examine the implications of the words themselves. Acute - know what that is. It is what Western medicine trains its future physicians to do well, to take people with an accident or a new illness and bring them back to their prior level of health and function. Acute is all about antibiotics, surgical interventions, surgical repairs, and the specialized place of that has the technology, equipment, and skilled technicians to work this modern day magic, the hospital. Acute in the United States at the end of the twentieth century is a marvel in so many ways, mostly because it does what it is supposed to do well. (The issues of adverse drug events, iatrogenic illnesses, and other such embarrassments keep the rating at very good rather than excellent) But what is For many, the phrase has negative connotations. It means all the hopes that go with acute are no longer present - the expectations of patient and provider alike that interventions can bring the individual back to the health and level of function that existed before the illness, condition, or accident - are no longer present. For many, longterm means that the hope of regained health and function are gone, and in its place is simply custodial care. The acute-care mentality says we can fix itAnd what Western medicine cannot fix (for example, arthritis, Alzheimer's disease, disability after a stroke) gets relegated to the next echelon, care. The physician all too often is out of the long-term- picture except as a figurehead (most of us of course are aware of notable exceptions,and applaud them). But the person needing this is just that - a person first, a person who needs, second, and a person who needs care, third. Is the that is needed long-term care or care? The phrase has a lot of baggage, as discussed in the previous paragraph. Perhaps the phrase inc can enable all of us to take a fresh look at providing necessary for an extended interval. So chn is the phrase use frequently in this issue, and hope the phrase represents a more optimistic construct for this panel of experts to examine and clarify. Let's ask the basic question, Who benefits most from appropriate integrations of acute and chronic services? and consider a few multiple-choice options. Response option A is the provider. Does the provider benefit? In some ways yes, in that conscientious primary providers would probably want to keep close contact and administrative control over an older patient under their care, particularly when the older person needs to be seen by a variety of providers with specialty training (such as cardiologists, radiologists, urologists, psychologists, rehabilitation specialists, occupational therapists, and a whole host of others). But that whole host of other specialists do not particularly benefit from appropriate integration of acute- and long-term- services. As specialists, they are asked to function in their specialized domain. Someone else typically has the responsibility of integration. So the specialists providing do not benefit from the integration of acute and chronic care, but the primary providers task of coordination of for the frail elder is facilitated by structural integration (see response option D for a fuller statement on structural integration). …