Designing Structured Regional Alliance Path Model for Healthcare Coordination Based on PCAPS

Abstract

A deficit in medical insurance finance has been observed with an increase in national medical expenses due to rapid aging, and the premium income does not increase.

Therefore, efficient functioning of all medical institutions, reinforcement of a coordinated medical care system, and effective practical use of this system are necessary. In this study, a coordinated medical treatment system is considered and a regional alliance path is designed as a tool that facilitates in improving the coordinated medical treatment system step-by-step. It clarifies the future of a patient’s condition by providing appropriate management and helps to achieve effective coordination.

Further, the regional alliance path helps to prescribe appropriate medical examination and treatment processes that each medical institution should follow by considering the processes followed by local clinics, and further, enables suitable distribution of community medical resources.

Introduction

National medical expenses continue to increase with rapid aging. The national medical expenses of Japan exceeded 30 trillion yen for the first time in 1999, and the ratio of national income reached 8%. Above all, geriatric medical costs show an annual growth of approximately 9%, and these have become the main factor contributing to the recent increase in medical costs. However, we cannot expect a large increase of the yield of taxes when the working population is expected to decrease due to rapid aging. Therefore, placing a restrain on the medical cost becomes the most important national problem.

There is a pressing need to obtain the background information on the means to control such medical costs and to reform the drastic measure adopted by the medical insurance system. One of the measure is the coordinated medical treatment by a function differentiation of the medical institution. It is believed that the coordinated medical treatment provided by local clinics and acute period hospitals, the diagnosis performed, and the medical treatment provided is effective for restraining medical costs when patients seek treatment at a certain area.

However, under present conditions, there does not exist a methodology for coordinated medical treatment. In addition, it is easy for patients to get admission into acute period hospitals, which increases the medical costs and exerts pressure on such hospitals.

Therefore, this study focuses on the coordinated medical treatment that is considered to be important for reforming the medical system and establishes a methodology for such treatment.

Purpose

We have so far developed the Master File of Standardized Nursing Practice Terminology2 (hereafter, the Master File), which provides nurses with the “common language” to describe their practice. Two expert nurses in respiratory care, an expert nurse in nursing informatics and a nursing administrator constructed the Standardized Nursing Care Contents utilizing the terms in the Master File.

The purpose of this study is to establish an effective coordinated medical treatment utilizing local medical resources that mostly comprise acute period hospitals and clinics. However, there is a big gap between the ideal coordinated medical treatment and the existing one (Fig. 1).

Fig. 1.

The gap between an ideal coordinated medical treatment and the existing one

In this study, we classify local medical institutions into primary clinics, specialized clinics, and acute hospitals and aim to construct a system by which each doctor can understand a patient’s condition and can select an appropriate medical institution for the patient.

It is difficult to change the existing coordinated medical treatment rapidly. Therefore, a step-by-step improvement of the system is necessary by using a regional alliance path. The regional alliance path is designed as a tool to understand the problem and the current state is clarified; “The way it should be” is considered as an approach to change the coordinated medical treatment.

We try to construct the model of regional alliance path based PCAPS [1] [2]

Method

This study focuses on a rapidly increasing urinary tract disease in Japan; the occurrence of the disease increases due to the changes in the recent eating habits. There are roughly two reasons for selecting this disease. One is that the disease can be treated at a primary clinic because it mainly requires a drug therapy. The other is that the treatment requires coordination between an acute period hospital and a clinic because the subjective symptoms of a patient and the severity of the disease do not always agree with each other, especially, prostate cancer.

A medical treatment involves a medical worker who provides the service and a patient who receives the service. In addition, medical workers who specialize in different fields are involved in a coordinated medical treatment. It is necessary to design a path by which a patient can approach medical workers who specialize in different fields. The following elements are necessary for designing the regional alliance path:

1. To understand a patient’s condition: The risk associated with a patient’s disease can be predicted by determining the present condition of the patient.

2. To clarify the coordinated routes: The selection of the medical institution is facilitated by clarifying the coordinated routes. As a result, each medical institution in a region can coordinate with other institutions to provide medical treatment, and the specialized services can be supplemented.

3. To clarify the Shift logic of the treatment that needs to be provided and: A constant Shift logic is shared with the management of the inspection and treatment, etc that should be provided by a unit in a region, and clinical intervention should be incorporated at the right time.

The diagnosis and treatment process were clarified based on the investigations made by doctors of an acute period hospital. Since patients suffering from this urinary tract disease often complained of urinary tract disease, this research targeted the patients with urinary tract disease.

The diagnosis and treatment processes followed by the acute period hospital were as follows (Fig. 2):

Fig. 2.

The diagnosis and treatment processes (at the acute period hospital)

1. outpatient, 2. basic inspection, 3. additional inspection, 4. internal medicine administration, 5. operation 6. adjustment evaluation, 7. operation, 8. hospital discharge, 9. pathage observation.

We investigated the diagnosis and treatment processes of each medical institution in a region in order to determine those that were suitable for taking charge of the diagnosis and treatment processes to be carried out under coordinated medical treatment. A questionnaire survey was performed in the clinics in the region. The questionnaire concerning the diagnosis and treatment processes of the urinary tract disease was sent to 23 clinics which have introduced patients to A hospital, and 22 clinicians replied to the questionnaire. The content of the questionnaire is whether a basic inspection and an additional inspection are inspected or not.

It was suggested that a primary clinic can operate a basic inspection, and it should provide an internal medicine for urinary tract disease and that a specialized clinic can operate an additional inspection, and it should perform a diagnosis and provide a treatment, other than surgical processes.

Result

a). Regional Alliance Path

From the hearing to the doctor of the acute period hospital and the questionnaire, we designed a regional alliance path by making the assumed route visible. The following figure displays it (Fig. 3).

Fig. 3.

The regional alliance path

Each of the coordinated routes is explained.

1. Reverse-introduction to a clinic from an acute period hospital

2. Introduction to an acute period hospital from a primary clinic

3. Introduction to an acute period hospital or a primary clinic from a specialized clinic

The three routes are as follows:

1. Reverse-introduction to a clinic from an acute period hospital

   Request for a pathage observation and internal medicine administration to a clinic

   As a rule, the acute period hospital reverse-introduces to the clinic which has introduced the patient, but a pathage observation should be performed in the specialized clinic.

2. A request for inspection from a primary clinic to an acute period hospital or specialized clinic

   After a basic inspection or an internal medicine administration in the clinic, the acute period hospital or the specialized clinic is requested to perform an additional inspection (consultation).

3. A request for operation from a specialized clinic to an acute period hospital

   After an additional inspection in a specialized clinic, the hospital is requested to perform the operation.

   After a basic and an additional inspection in a specialized clinic, the specialized clinic reverse introduced to a primary clinic.

b). Transition Logic

It is believed that coordination between local clinics and hospitals is achievable through the coordination path. However, each clinic specializing in a different field treats patients with urinary tract disease differently. It is natural for the technologies of a medical treatment to differ, and thus, it is very difficult to standardize a treatment technique. Therefore, it was believed that the cooperation should be enhanced based on the transition logic.

Then, the transition logic was decided based on the evidence (Table. 1).

Table. 1.

Transition logic

Present unit	Shift logic		Shift unit
C-1	The clinics which prostate dilation syndrome is not treated or The patient’s condition that it is not possible to urinate or the serious patient’s condition		A-2 or B-2
C-2	Rectum examination	The prostate is enlarged. The prostate touches hard.	A-3 or B-3
	Urine test	There is an urinary tract infection.
	Serum – Cr examination	Serum – Cr ≧ 1.7 and the patient’s condition that it is not possible to urinate	A-3 or B-3
	PSA measurement	50 ∼59 year PSA≧2.5, 60∼64 year PSA≧3.1 65∼69 year PSA≧3.5, 70∼74 year PSA≧4.0 75∼79 year PSA≧5.0, over 80 year PSA≧8.0
C-3	Even if α - blocker is administered for 12 weeks, it is resistance or it is an uneasy case to treatment. or When you cannot administer α - blocker due to low blood pressure and allergy, etc		A-3 or B-2
B-3 or B-4	To need operation		A-5

c). Verification of applicability of the regional alliance path

We investigated the clinical records about the prostate dilation syndrome and the prostate cancer with a difficult discrimination. We referred to information on the introduction cards for a coordinated route and a coordinated standard, and referred to the clinical records for past treatments and inspections. We verified each case on the regional alliance path. The coordinated routes and the ratio of the prostate dilation syndrome and the prostate cancer are shown.

For prostate dilation syndrome (Fig. 4).

1. From a primary clinic (outpatient unit) to an acute period hospital (50%)

2. From a primary clinic (internal medicine administration unit) to an acute period hospital(17%)

3. From a specialized clinic (additional inspection unit) to an acute period hospital(33%)

Fig. 4.

The coordinated routes of prostate dilation syndrome

For prostate cancer (Fig. 5).

1. From a primary clinic (basic inspection unit) to an acute period hospital (55%)

2. From a primary clinic (internal medicine administration unit) to an acute period hospital(27%)

3. From a specialized clinic (basic inspection unit) to an acute period hospital(9%)

4. From a specialized clinic (additional inspection unit) to an acute period hospital(9%)

Fig. 5.

The coordinated routes of prostate cancer of prostate dilation syndrome

The verification result of the coordinated routes of the prostate dilation syndrome and the prostate cancer are shown. From these results, it is understood that the regional alliance path covers all coordinated patterns. Therefore, it is applicable for the prostate dilation syndrome and the prostate cancer.

d). Verification of utility of the regional alliance path

The utility of the regional alliance path is verified. We investigate whether it is effective to use it for a improper coordinated pattern.

An improper coordinated route of the prostate dilation syndrome is shown (Fig. 6). It is a pattern that coordinated with the acute period hospital without the symptom improvement after the internal medicine is administered in the primary clinic. In this case, the period from the internal medicine administering beginning to coordinate to the acute period hospital is 6months. It is an example of the delay of the medical treatment intervention. However, it will be possible to coordinate in 12 weeks after the internal medicine is administered if we use the regional alliance path and the shift logic. Therefore, the improvement of the quality in the medical treatment by Delivery (early treatment) and Cost (decrease in the internal medicine cost), etc. can be hoped for.

Fig. 6.

The coordinated route from the primary clinic ( internal medicine administration) to the acute period hospital (Additional inspection)

Next, a improper coordinated route of the prostate cancer is shown (Fig. 7). It is an improper example which the medical treatment intervention was delayed.

Fig. 7.

An example coordinated route from the primary clinic to the acute period hospital of prostate cancer

It has not been coordinated medical treatment though PSA examination was inspected. And, the internal medicine of the prostate dilation syndrome was administered for three years, and the clinic doctor’s having introduced the patient to the acute period hospital.

If the shift logic is used, it is an example which the early stage detect can be done. An early stage detect of the prostate cancer and a needless internal medicine administering might have been able to be prevented if we used the regional alliance path. In a word, the quality in medical treatments such as delivery and cost will improve by use of the path.

Conclusion

The maximum effect achieved by using the regional alliance path is beginning of treatment at the early stage. A coordinated route was able to be shifted along with it, and it was thought that the quality in the medical treatment was improved, and got good results Delivery (It was beginning of the treatment in the early stage) and Cost (Useless internal medicine treatment is prevented). Therefore, the utility by the operation of the regional alliance path is an early stage detect of the disease and control of the medical treatment expense.

Now, we try to add Nursing office for home care delivery and Tele-consultation as players in this Model. It is suggested that they are effective for healthcare quality improvement.