Shirah Vollmer MD

The Musings of Dr. Vollmer

Continuity of Care

Posted by Dr. Vollmer on March 28, 2016

The passionate ranter returns. In light of the changing quality of mental health care, there have been numerous issues which have concerned me deeply. Medication management appointments which are fifteen minutes, for example, remind me how superficial and impersonal my field has become. Worse than that though, is that in newer, larger, systems of care, there is a greater emphasis on seeing a “provider” rather than “your doctor”. As if all providers are interchangeable. The move towards automation, in general, has poured into health care, such that the more the system can operate independent of individuals, but rather on groups of individuals, the stronger the system will be. If the system were dependent on a few highly trained professionals, than their departure would wreak havoc with the overall mission of health care, and so now large medical centers are ensuring that care can be handled by a number of providers and so there is less vulnerability. In the world of mental health care, and in particular, in the world of addiction recovery, there is no value placed on seeing the same provider throughout treatment, but rather the value is “being in rehab” meaning that all programs are treated equally and historical perspective is not valued. It reminds me of working on various boards where historical knowledge, perhaps the most critical way of understanding how to get things done, is not considered and certainly not valued. So, too, with mental health care, it is as if the insurance companies have a check-box, such that if someone has a “substance use disorder” then they need to go to a “recovery place” which, as far as they are concerned could be anywhere in the country. If the patient relapses, they could then go to a second “recovery place” which could also be anywhere in the United States, and on it could go for upwards of twenty to thirty rehabs, in extreme examples. My solution, you ask? I propose that fictional patient Erika, for example, be assigned a treatment team, and that treatment team stays with her through her lifetime. Of course, changes could be made, but by and large, this team has stability for her. She will not have to repeat her life history, time and time again. She will have a relationship with her team that gives her the comfort and security to propel her forward in her life, and at the same time, gives her a safety net if she steps backwards. This is a simple idea. It does not cost more money. Why can’t we do this?

 

Perhaps the reason has to do with a vast network of providers who bounce patients back and forth as a way of taking financial care of one another. Or, maybe the reason is that there is a hopelessness about therapeutic relationships. Perhaps no one has the conviction that therapeutic relationships, as the name implies, helps patients heal. Or, maybe the addiction field, in particular, is in its infancy, and as such, needs to grow up to understand this. As with all of my rants, the answer comes from listening. Patients will tell you, if you ask, that they need this continuity, and without it, the treatment programs will  not work. My hope, as I explain to my patients, is that with a greater emphasis, and a greater measurement of patient satisfaction, this issue will come to light. Patients, although vulnerable, by definition, have the power to complain about their care. Maybe with  big data analytics, this issue will have power. I hope so.

2 Responses to “Continuity of Care”

  1. Shelly said

    Maybe I don’t understand addiction care. If a recovery plan doesn’t work, doesn’t it make sense to change it? Like in treating high blood pressure–if one medication doesn’t work, don’t you change it to another? Or does all the work depend on the interaction between patient and team? Do you change the team if the treatment doesn’t work? Because obviously one can’t change the stressors that cause the behaviors but one can change the reactions to the stress or the treatment plan or the treatment plan itself. Please enlighten me because like the insurance companies, I’m not sure I understand why you don’t change treatment plans.

    • The issue is the following; Patient Erika, in this example, is an addict. She wants to get clean so she goes to rehab and in so doing is seen by a treatment team consisting of a psychiatrist, a psychotherapist and a rehab counselor. Then, Erika is discharged and relapses, as is so often the case. She then goes to a second rehab because she thinks she will do better there, and so now she has a new team and she has to tell her story all over again. This cycle can go on for many years, each time, with a new beginning. As far as the insurance companies are concerned, they do not care which rehab they pay for, so there is no problem there. I am saying that if Erika had to return to team A, she would have a better chance of a lasting recovery, because she would be known to the team and she would not have to start over again. I am hopeful that eventually insurance companies will learn this, but at the moment, patients like Erika can fly all over the country going to numerous rehabs and there is very little accountability in any direction. Thanks.

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