Inpatient Care Reform from a Community Nurse Perspective

I have worked in health care for over 20 years focusing on care in the community through parish nursing or faith community(FC)nursing. Our practice provides for wholistic care - addressing the body, mind and spiritual needs of the client in the faith community (FC) setting. In our role we see clients of all ages, demographics and situations. From the patient with insurance, multiple resources and strong support systems to the homeless. From my perspective 2 major issues related to health reform come to mind. First, as you have mentioned in your postings, simply access to inpatient care is a major issue. Far too many US citizens have limited or perhaps no access to health care resources and thus the wonderful inpatient care available in the US. Despite the fact that there are governmental programs to support them many times there are significant barriers that still prevent access. Barriers such as language, an address, transportation to the site to apply and maintain programs and then when accessed the support to be able to maintain the coverage. The second issue is very different. As healthcare is becoming more expensive and resources for all are dwindling it is critical that these resources be used as efficiently as possible. Quality in health care can make a significant difference in how much money is spent to provide care. If hospitals can function more effectively and efficiently I would propose that we would have more health care dollars to care for all. Efforts to improve qualilty in inpatient care by rewarding hospitals that meet standardized quality measures and holding physicians accountable for standards that have proven to lead to best outcomes are already making a difference in our healthcare structure and in reducing health care costs. Such efforts focus on quality care through evidence based practice and are successful only when all parts of the HC system are held accountable. In the past physicians and hospitals have and continue to be reimbursed for the amount of care they provided, not necessarily the quality of their care or the outcome. Closely related to quality in health care is the issue of safety in our inpatient care. Efforts to use technology to improve medication errors and eliminate documentation errors (that can lead to patient care errors) are examples that reform is happening. Now if only we could find the reform that would eliminate patient falls.

Patient Perspective- Guest Author

The following is the story told by a patient but has been typed by Lindsey:

" My Husband worked for the World Bank, so I traveled all over the world. I've had 6 kids and not all of them were born in a developed country, so I think I've probably had a lot more experience with different inpatient care than a lot of other people have. Some good experiences, some bad. My first three kids were born in the United States, and I was either knocked out for those or put into "twilight birth", which was when you were kind of there but not really and you didn't remember anything when it was over...All I do know is that the whole process was complicated and NOT exciting...so by the time I was having my fourth child around 1965, I still didn't really know anything about childbirth. I was having really bad cramps, which if I had known anything about childbirth, I would have known it was a bad sign. I started to hemorrhage as I waited for my husband to come home. I lost so much blood that I remember not being able to lift my head without feeling the world spinning 100 miles an hour!! Finally my husband came home (there weren't cell phones so I just had to wait for him to get home from his office) and took me to the hospital. Long story short--my baby only lived for two days after I gave birth. His lungs were not developed enough. It was the worst day of my life.

The day after my son died, my doctor came in my room, as I was still recovering, and asked me if I was nursing yet. I started at him and broke down crying! I told him that our baby had died and he said, "ohh...I..umm...forgot". What a jerk!! It would have taken him but two seconds to read my chart to know that, instead he added insult to injury. My own doctor had not even enough time to know the traumatic situation I was in. It was horrible.

I gave birth in the United States to the next two children and they also seemed very complicated and not as joyful as I thought they should be. The most joyful and easiest birth I gave was to my last child, in a third world country (1971). I was in Northern Africa (our family was traveling with my husband). The hospitals were DIRTY and filled with cats. The cats kept the rodent population down--so I always said I would rather have cats than rats!! Here the nurses were the "lowest" jobs for women. It was the women who were uneducated and poor and they hated their jobs! They couldn't read your chart and they were not happy to be around you. The saying always was that "surviving the surgery here isn't the problem, its dealing with the nurses that is thought to survive"! The hospital beds were like you see in old war movies, just many in a room, not comfortable, and dirty! Luckily, we found a clinic that didn't have cats (or a rodent problem)! This clinic was able to survive because this is where the President went, who kept it functioning (not that it was expensive at all, compared to the US). The physician there was trained in the US. I was nervous because they were not going to give me pain medication to give birth, instead I had to go through classes to learn how to breathe correctly and things like that for giving birth. My husband was helpful and in the room as I was in labor. He read a nursing book to me, explaining everything that was happening. At one point he began to hyperventilate and passed out on top of me AS I WAS GIVING BIRTH! There were only two ladies there helping me with the birthing process. Both of them were not more than 5 feet tall and skinny as a rail! My husband...6'2 and 290lbs was difficult for them to move. Meanwhile, my daughter was crowning. I told them to push him to the floor but for some reason the insisted on dragging him into the other room...leaving me to deal with giving birth on my own for a moment or two. Even after all of that, I still felt that the process was easier than the rest of my births and I look back at it and laugh! The doctor was so friendly. I later found out that my daughter had actually breached, which is a much more dangerous birthing process than normal--but I never felt like it was! Nevertheless, the conditions were almost scary and I couldn't wait to leave. I would not give birth there again.

However, the US is not the best inpatient healthcare I have ever received. I always tell people if they travel anywhere (and especially if they plan on being reckless) they should go to Thailand because the quality of care I received was way better (when I was treated in 1985) than anything I have ever experienced in the US (and I have had surgeries in multiple states and during multiple decades--including recently). In Thailand, which at the time most people considered a 'third world country', the hospitals were clean (no cats or rats!ha-ha!) and the people were so caring and patient with the healing process. In 1985, while in Thailand for the first time my husband, me, my youngest daughter (than 14), and both my parents were driving to go to a couple of vacation sites. Usually everyone takes the train because it is cheap and the roads are dangerous (because of bandits). Only truckers drive and because they are paid for how many trips there make, they were on all sorts of uppers and downers. My stubborn husband wanted to drive anyway, so we did. The truckers were playing games with him--speeding up and slowing down--so he tried to pass them...we were hit head on by a gas truck! The three of us in the back (me, and my parents) were the worst and all of us had head issues. The "ambulance" was a pick up truck with wired gates at the end, that they loaded us into (so that wasn't the good part of the care!). My left femor bone was completely shattered, but all I knew at that time was that it looked tangled. They took us to a rural hospital and because we had friend in Bangcok we got an ambulance to the hospital there. The physician from the rural hospital didn't think my dad would survive the trip so he came with--and kept him alive! Long story short, the quality of care there was amazing. My dad had to have brain surgery and it went very well. They even placed him in my room and didnt charge us for it because we didn't know if our insurance would cover it. When we found out it did, they still didn't charge us. They cared so much. I had reconstructive surgery on my leg and the rehabilitation I was given was beyond anything I have ever recieved in the US. When I got back to the states, I had pins and screws that were in my leg that needed to be taken out. Every doctor that looked at my leg told me that whoever fixed it did an amazing job and I was lucky. They also told me that they weren't going to mess with it. I don't think this was because I didn't have the insurance for it--but I thought most likely it was because they didn't want to be liable? I still don't know why. I returned to Thailand and that same doctor took them out for me. The physcian in Thailand went to school in the States but seemed to provide more care for me as an individual than many of the doctors I see in the United States. I have found a place I trust in the area and I like it there...but I would return to Thailand to be taken care of in a heartbeat.

A Medical Student View

As a first year medical student at the University of Wisconsin School of Medicine and Public health, I have been exposed to inpatient care right from the start; which highlights its importance in my future profession. One model of healthcare delivery that seems to relate to reform proposal 2’s argument for greater access to care to prevent medical emergencies as well as well as reform proposal 1’s focus on coverage for pre-existing conditions is the “medical home” model. It stresses a long-term relationship with a primary care provider, extensive integration among the different members of a patient’s care team, and a focus of the “whole” person as opposed to their relevant symptoms. An important aspect of this model is electronic records to facilitate integration and improve quality and safety. Electronic medical records, and other health promoting and potentially cost effective stratigies (for example community health promotion/education programs and increased access to primary care providers, ) come with a price. While these improvements that would eventually save money in the long run they are a large financial commitment initially, and especially difficult to garner support for in a tough economic climate.

An important aspect of impatient care is quality control. In the past, healthcare has been different from other service providing entities in that there was less focus on cost effectiveness, quality of care, and efficiency. This was a time when there were fewer options for places to go to receive care, and patients’ role in their care was one of taking orders. Things have changed, and with more options for care, a more business-minded approach to healthcare, and patients’ taking a more active role in their health, efficiency and cost effectiveness have become just as important as in any other business. While I see the positives of reducing wasteful and unneeded tests and procedures, it has been an adjustment integrate a business view of medicine that I didn’t really consider when I decided to enter the field of medicine.

Another strategy for efficiency and cost-effectiveness is “pay-for performance” measures for physicians. A discussion of this public health class brought up questions of how exactly to measure performance and outcomes, and how this assessment would differ for physicians with vastly different patient populations. In any healthcare delivery environment, following evidence-based, facility supported practices is important, and this is especially true in inpatient care. Many situations have predictable and proven decisions that follow, and if the evidence is behind it, it makes sense to follow it. I also think physicians should be held accountable for their decisions and take cost considerations into account when making decisions. I do worry about that making medicine more of as algorithm following science than an interpersonal art takes the personal touch out of medicine. I also wonder if the measures could have the potential of focusing on efficiency and cost effectiveness to the point that quality of care could decrease and decreasing needing procedures/tests could have the potential to be rewarded.

I can appreciate both sides to the universal healthcare debate. What I feel strongly about is that there are for too many people without access to care and that any legislation passed to improve the health of this nation will look at the “upstream” reasons that bring people to the hospital in the first place.

A Nurse's Response

Health care reform has been on the lips of politicians for years but the reality is little seems to change. More than ever Americans of all ages with and without insurance are not receiving appropriate care. Strong insurance companies have successfully leveraged their clout to limit or end coverage when care is most needed. Sister to the insurance companies are the very successful drug companies that much to our benefit are finding wonder drugs to address health issues. Unfortunately the cost for medications has made this a HC resource unaccessable to many. So I would say that one of the most important issues related to reform in inpatient care is access.

Guest Author Kris, Patient

My experiences with inpatient care have all been pretty positive. I am always a nervous wreck when I’m away from home in an unfamiliar place, so that part of it was uncomfortable. During my three C-sections, I was awake, which took some of the pressure off compared to during my surgery when I was put under. After that surgery, I was in a lot more pain than during (and after) the C-sections. In the OBGYN ward, the air was always light and cheerful, probably because of the happiness with all the new babies. It was tenser in the surgical ward because of the seriousness of the surgeries. I was always very confident in my surgeons and caregivers, and I trusted that they would do everything they could to help me. In my experience, all of my caregivers were very professional. The food was never as good as at home, but the dietary aides were very nice. The pharmacy always came up to explain my prescriptions to me before I began taking them, and pain control was a huge factor. They always wanted to keep me as comfortable as possible, but with the least amount of medication possible, which, looking back on, I really appreciate. The occupational therapy department came in daily to help me with my ADLs (activities of daily living). They wanted me to do everything I could on my own as soon as I could, but they were always there to supervise if I should have trouble. I remember the visiting hours were always very fair too. They even let my husband Pat stay a couple hours past the visiting hours one night because they knew it had been a rough day for me. That compassion really sticks out looking back at my hospital stay. As far as cleanliness, I have a hard time finding anyplace as clean as I think it could be, but I would give that hospital an A- for its cleanliness, which is pretty good coming from me.
The only negative experience I can recall about my stays in the hospital would be when I had my first child. Every other pregnancy I had a private room, but with Katie the hospital was renovating the OBGYN ward, so there were two active labor mothers in one room. That was a little stressful, but I know they were doing the best they could in the situation. Other than that, I really have no complaints about my stay in inpatient cares, as my experiences have all been positive ones.
--Kris

Inpatient care health reform proposal 2

The United States is in great need of health reform. The inpatient sector of health care is suffering and measures need to be taken in order to ensure quality and access to the approximately 308 million individuals living in America. This reform proposal focuses on the role of the hospital in inpatient care. According to the 2006 National Hospital Discharge Survey there are 34.9 million discharges a year from U.S. hospitals. This number does not include the 15.3 million emergency room visits which result in admission into the hospital.¹ One can see that inpatient care is a crucial sector of the health care system. Therefore, a change needs to be made to the health system to not only ensure that inpatient care is maintained but also improved. Something needs to be done about the 47 million people who are permanently uninsured as well as the 43 million who spend a lot of their time uninsured.² According to Ricardo Guggenheim, MD, for HealthLeaders News stated that, “We have an uninsured crisis in our country that is creating great imbalances in the healthcare delivery system. A significant source of this imbalance is the result of the large number of uninsured patients that are turning to hospitals for medical care.” He then continued to explain that the majority of uncompensated care is delivered in hospitals. Hospitals nationwide, in a single year, provide 31.2 billion dollars of uncompensated care. As a result, many health systems face shutting down because they cannot deal with the financial loss they face by providing services which they are not compensated for.² This creates new issues because as the population ages, it is likely that the utilization of inpatient care will rise and we can’t afford to be losing hospitals. We also can’t afford to lose emergency room services because ERs are greatly utilized currently and are already overcrowded. According to the National Hospital Ambulatory Medical Survey there are 119.2 million emergency department visits a year.

It is clear that we need a solution to these financial problems created in inpatient care. The solution: universal coverage. Congress needs to pass a law that ensures that all Americans will have health insurance coverage. This would eliminate the financial burden hospitals currently bear due to uncompensated services. It would also improve access to inpatient care because there would be room for those who truly needed to stay in the hospital. Quality of care for patients in the hospital would also be better because there would likely be fewer patients for each physician to be responsible for. This would occur because, in our current, situation many hospital beds are filled with people who do not actually need emergency care. According to Guggenheim, many uninsured individuals currently use the emergency room for chronic health problems that become uncontrolled. If they are admitted to the hospital, they are released once their condition stabilizes but they will eventually need to be readmitted. Universal coverage will allow these people to get the medications and follow-ups they need to keep their chronic conditions under control and it will alleviate unnecessary hospital use.² According to John S. O’Shea, M.D., “In Maryland, for example, patients with non-urgent medical problems account for over 40 percent of ED visits.” ³

Some individuals believe that providing universal health coverage will create more problems for the health care system than it will fix. They believe that it will create a lot of issues when trying to receive outpatient care because so many more individuals will be accessing care. It may be true that more will seek care with primary physicians, but it will also free up the hospital emergency rooms which are currently overcrowded. Why is this so important? When emergency rooms and hospital beds are filled with individuals who could be treated in an outpatient center, care may be delayed for individuals who need emergency medical attention, which is a much more serious problem than having to wait a few days to see a primary care physician.

This reform proposal is more important that other reforms because it is crucial that hospitals are not closing due to financial burden caused by uncompensated care; this will cause further problems for the health system. The inpatient sector also needs to be taken care of so that the quality of care does not suffer for those who need serious medical attention. It is also important so that access to hospitals improves so that those in serious need can be taken care of.

Sources:

1. Hospital Utilization (in non-Federal short-stay hospitals). Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/FASTATS/hospital.htm. January 18, 2010. Accessed March 9, 2010.

2. Ricardo Guggenheim. Uncompensated Care is a $31 Billion Problem Waiting to Be Solved. HealthLeaders Media Web site. http://www.healthleadersmedia.com/content/220119/topic/WS_HLM2_LED/Uncompensated-Care-is-a-31-Billion-Problem-Waiting-to-Be-Solved.html. September 26, 2008. Accessed March 9, 2010.

3. John S. O’Shea. The Crisis in America’s Emergency Rooms and What Can Be Done. The Heritage Foundation: Leadership for America Web site. http://www.heritage.org/Research/HealthCare/bg2092.cfm . December 28, 2007. Accessed March 9, 2010.

Inpatient Care Reform Proposal 1

According to an article at Health Care Reform.gov, “pre-existing conditions affect millions of Americans”, leaving healthcare unattainable for many of these millions of Americans (5). Congress needs to take action to require insurance companies to accommodate all people with pre-existing conditions. As said by the International Medical Insurance dictionary, pre-existing conditions are defined as “any illness or injury that has manifested symptoms or is known to an individual prior to the start of a policy”. (4) Many insurance companies are currently required to insure people with pre-existing medical conditions, but many do so only with a pre-existing exclusion period, so there is a stretch of time that insurance does not accept claims related to a client’s prior condition. (1) By eliminating these exclusion periods and requiring all insurance companies to insure those people with pre-existing medical conditions, insurance company “cherry-picking” would be more tightly controlled, and insurance companies would cover much more of the currently uninsured population. The Health Insurance Portability and Accountability Act of 1996 (HIPPA) has helped to stop some cherry-picking by preventing discrimination against people with prior medical conditions. The US Department of Labor did a great job explaining how and when HIPPA requires most insurance companies to cover people with pre-existing conditions, but still allows for the varying exclusion period, which can range from six to 18 months (2). Also, under most circumstances, in order to get the “short” exclusion period of six to 18 months, you have to have prior, uninterrupted health insurance, which nearly 50 million Americans unfortunately do not (3). For a cancer or diabetes patient, eighteen months is a very long time to have to cover your own hospital bills.
This reform would undeniably cut down the amount of families that go through medical bankruptcy because more families with diseases and/or conditions requiring frequent medical conditions would be held less accountable for paying for their medical bills out of pocket. Also, access to health insurance would become available to many more people, some which include cancer patients, people with diabetes, and the more and more prevalent problem of patients with high blood pressure. Incorporating this reform into our health care system would better the outcomes of the population because so many more people could receive health care when they need it. This could decrease future health bills because preventative tests/procedures could stabilize the patients’ condition further, leading to less frequent hospital or emergency room visits.
Another current reform is arguing that more money needs to be spent on in-home care rather than long-term care in nursing homes, because long-term care in nursing homes is more expensive for Medicare than in-home care would be. While I feel this is also an important step to consider in our current health care system, I think that we need to focus on getting more people covered by insurance first. If we do not, people with declining health will end up in the nursing homes or in long-term home cares even sooner than they already are, which would cost even more money. People with pre-existing conditions are more likely than healthy people to end up in a long-term care facility anyway, so without getting them health insurance coverage, they will be more at risk to enter into medical bankruptcy, if they can even afford to enter into long-term care at all.
Some people may argue that covering people with pre-existing conditions is not as important as getting the poor and underinsured populations insured. While there may be some relevant points to this, much of the pre-existing conditions population will soon become poor and underinsured, as many of them are already, because insurance will not cover their current medical bills. If we can prevent this from happening, we can keep the poor and/or underinsured population from escalating out of control and once this proposal is put into place, we can turn our attention to the remaining poor/underinsured population.


1. Bihari, MD, Michael. Pre Existing Conditions - Understanding Exclusions and Creditable Coverage. About.com, 8 Feb. 2010. Web. 1 Mar. 2010. http://healthinsurance.about.com/od/healthinsurancebasics/a/preexisting_conditions_overview.htm
2. FAQs About Portability of Health Coverage and HIPPA. United States Department of Labor, n.d. Web. 1 Mar. 2010. .
3. How Pre-Existing Conditions Work. How Stuff Works, 2010. Web. 2 Mar. 2010. .
4. Key Terms and Definitions. International Medical Insurance, 2010. Web. 1 Mar. 2010. .
5. US Department of Health and Human Services. Coverage Denied: How the Current Health Insurance System Leaves Millions Behind. United States Government, 1 Mar. 2010. Web. 1 Mar. 2010. ..