Improving and Reforming
Long-term Care
Part 1: The Biological Foundation
Steven A. Levenson, MD, CMD
1
“Reform”

“Reform” is in the air


But just what does “reform” aim to fix?
Reform


Improve by alteration or correction of errors or
defects and put into a better condition
Make changes for improvement in order to correct
abuses

Source:
http://www.google.com/search?hl=en&q=define%3A+refo
rm&btnG=Google+Search&aq=f&oq=
2
Reform Hurdles

“AMA to White House: Don't Dictate
Care” [3/9/09]


http://www.healthleadersmedia.com/content/229394
/topic/WS_HLM2_HR/AMA-to-White-House-DontDictate-Care.html
“Any attempts by federal government to
use evidence-based medicine to dictate
how physicians provide individualized
care would be a deal breaker”
3
Reform Hurdles


It isn’t just patients and doctors
Health care reflects and impacts all major
social institutions

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Education, government, economics / commerce,
families, law
Oversight, attempts to change performance,
enforcement all reflect and influence health
care

Reflect beliefs and methods; for example, how to
investigate, draw conclusions, define truth,
identify correct actions, attribute cause and effect
4
Who Can Reform What?


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Limitations of legislatures and political processes in
bringing about true reform
Many of us are having trouble changing our thinking
and actions
Non-therapeutic substitution

“In American culture, prescriptions and procedures have become
surrogates for real health care and real dialogue,” Dr. Newman
said. “We need doctors and patients to conceive of medicine and
health in a totally different way than they have been taught in the
last 20 to 30 years.”

Source:
http://www.nytimes.com/2009/03/03/health/03well.html?scp=14&sq=
health%20care&st=cse
5
Reform Efforts


How much do current efforts really
being about meaningful change and set
appropriate expectations?
Not surprisingly, current approaches are



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Often uncoordinated
Sometimes self-contradictory
Don’t consistently result in good care
May not define issues correctly or identify
root causes
6
Reform: Prerequisites

To reform something effectively, it helps to
understand what we are trying to improve

Clear issue statement



Causes of imperfections and problems
What it should look like when done




Nature and components
What should be changed or strengthened
Options for changing things
Obstacles to implementing reform
Options for overcoming obstacles
7
Our Subject Matter

What will it take to do this right?






A cohesive strategy and a meaningful plan
Understand and apply biological foundation
Reconsider current improvement and
reform efforts
Challenge the conventional wisdom
Widespread, consistent accountability
Rethink the research agenda
8
Our Subject Matter

What will it take to do this right?

Focus attention on basic care principles
and processes





Promote desired performance and practice
Suppress reductionism and jurisdiction
Reconsider notions of competency and
expertise
Change approaches to assessing and trying
to improve quality
Develop biologically sound reimbursement 9
What Can We Each Do?
10
Solution is Straightforward
11
Mostly Self-Evident
12
Logically Consistent
13
Little Changes Add Up
14
Key Principles
What constitutes biologically
sound care?
15
16
The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
17
Homeostasis

A key biological principle


Adequately functioning organ systems adjust
to compensate for stresses


An organism maintains relative stability through
constant internal adjustment
Including imbalances and impairments
Disease and organ failure may


Cause or exacerbate imbalances
Impair physiological reserve capacity
18
Homeostasis: Water Balance

Maintaining water balance
19
Homeostasis: Blood Sugar

Blood sugar regulation
20
Personal and Psychological
Homeostasis


Similar to physiological homeostasis
Individuals strive for psychological
balance and adequate function

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To thrive in personal and social setting
Personal and psychological homeostasis
require adequate physical homeostasis

Example: function and mood may decline
when major medical illness causes physical
instability
21
Health, Illness, and
Impairment

Health can be defined as “a state of complete
physical, mental and social well-being and not
merely the absence of disease or infirmity” World Health Organization (WHO)


http://www.who.int/about/definition/en/print.html
Limits of health care in producing complete
well-being (i.e., health)

However, can have profound effects, for better or
worse
22
Key Biological Principles:
When Things Go Astray

Symptoms and risk factors have causes


Often combined effects of multiple issues
Causes and consequences have various
relationships

Defining those links is crucial to providing
safe, effective, and patient-centered care
23
Biologically Sound Care

“Quality of life” and “quality of care” are
inseparable in all settings


Effective care is based on linking each person’s
physical, functional, and psychosocial causes and
consequences
The essence of “individualized (personcentered) care”


Requires “context” of underlying causes and
consequences
Recognizes that interventions may be beneficial,
inconsequential, or harmful
24
Causes and Consequences
Consequences 
Causes
One
Multiple
One
Multiple
+/+
+ / ++++
++++ / + ++++ / ++++
25
Causes and Consequences



All consequences (e.g., impairments,
symptoms, complications) have causes
Causes and consequences occur in four
major patterns and relationships
Clarify links among causes and
consequences

Basis for providing care in any setting
26
Causes and Consequences
27
28
Causes and Consequences
(1:1)

One cause  One consequence (1:1)


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No other factors involved
Usually occurs in otherwise healthy people
or those with minor chronic conditions
Examples


Fracture  impaired mobility until fracture
heals
Fatigue  headache for a few hours
29
Causes and Consequences
(1:Multiple)

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One cause  multiple consequences
Example

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Major stroke in previously well individual 
impaired mobility, self-care deficit, pain,
altered nutritional status, altered mood
Altered family processes mood disturbance
 social withdrawal and behavioral symptoms
COPD (advanced)  activity intolerance,
altered breathing patterns, impaired gas
exchange, self-care deficit
New and old impairments may interact to
increase risk for additional impairments
30
Causes and Consequences
(Multiple:1)

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Multiple causes  one impairment
Example

Hydration or depression risk due to

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CVA and dementia (neurological), chronic renal
failure (urinary), colitis related to antibiotic use
(gastrointestinal)
Pain due to

Parkinson’s Disease (neurological),
osteoarthritis (musculoskeletal), side effects of
medications used to treat hypertension or lower
blood lipids
31
Causes and Consequences
(Multiple:Multiple)

Multiple causes  Multiple impairments

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Very common in short-stay and long-stay
nursing home population
Example

[New stroke + diabetes + ischemic
cardiovascular disease + chronic renal
failure + medication side effects + mood
disorder]  [impaired mobility + pain +
social withdrawal + altered nutritional
status + impaired fluid balance + pain +
risk of altered skin integrity]
32
Linking Causes and
Consequences

Four essential steps before interventions
1) Characterize the disabilities
2) Identify causal impairments
3) Determine specific diseases underlying identified
causal impairments
4) Discover any contributing factors

Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric
rehabilitation: State of the Art. J Am Geriatr Soc
45:1371-1381, 1997
33
Biologically Sound Care: Key
Underlying Principles


Impairments may often be prevented or
improved by treating underlying causes
Important to

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Identify all causes of impairments, to extent
possible
Determine which ones can be addressed and to
what extent
Choose interventions in the context of the whole
situation, not just one symptom or risk factor
Try to optimize—not undermine—physical
condition
34
Biologically Sound Care: Key
Underlying Principles

Interventions may prevent or correct
physical impairment by



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Resolving underlying cause(s)
Improving homoeostatic balance
Maintaining or improving physiological
reserve capacity
Reverse impairments
Lessen severity or help reduce progression
to disability
35
36
Biologically Sound and
Unsound Care

Sound

Care of person with [Condition A + Condition B +
Condition C + Condition D + Condition E]
≠

Unsound

[Care of Condition A] + [Care of Condition B] +
[Care of Condition C] + [Care of Condition D] +
[Care of Condition E]
37
Care in Context

Coordinated and integrated care of
people

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Especially those with multiple issues
Consistent with biology because it

Takes each symptom, condition, risk, or
problem in context

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Including sequence of events
Identifies proper combinations of cause-specific
and symptomatic interventions
Promotes care that optimizes physical,
functional, and psychosocial homeostasis
38
Care in Context

Fragmented or uncoordinated care
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Biologically unsound because it

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Approaches issues as distinct entities
Fails to identify root causes
Fails to address causes and consequences in
proper context
May cause new or additional complications
while trying to address issues in isolation
39
40
Patient History and Context

What are the likely differences in cause,
approach, and context if someone



Gets delirium and then gets anorexia
Gets anorexia and then gets delirium
Has a significant condition change with
change in mental function and anorexia at
the same time
41
Health Care Role
What is the role of health care in
providing biologically sound care?
42
Implications for Care Provision

Key goal of all health care


Effectively integrate interventions and
services related to physical, functional, and
psychosocial dimensions
Key goal of medical care

Help individuals attain and preserve
enough physiological function to enable the
greatest possible personal and
psychosocial function

Within limits of what’s reversible / preventable 43
Reform and Improvement
How and why do these principles
affect efforts to improve health
care?
44
Essential Support for Reform


Mutual influence between health care and all
other social institutions
Other social institutions and public policy
must



Reflect and respect underlying biology
Understand what they are alleging to try to
improve and reform
Promoting “individualized” care means much
more than just functional and psychosocial
interventions
45
Essential Support for Reform

Less helpful efforts


Promote interventions out of context
Focus on fragments of the care delivery
process

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For example, care planning or treatment
Are too focused on artificial distinctions

Such as “medical” and “social” models of care
46
Long-Term Care Reform
Problem Definition and Cause
Identification
47
Approach to Long-Term Care
Reform

IF biologically sound care is required in order
to meet key quality attributes



Safe, effective, efficient, timely, equitable, patientcentered
AND only some of the care is biologically
sound
THEN

We must focus on improving the biological
soundness of all care, in all settings
48
Approach to Long-Term Care
Reform



IF the three human dimensions are closely
related
AND long-term care only partially reflects that
reality
THEN


We must focus on properly integrating and
coordinating services in all settings
We must suppress and reverse excesses of
thinking about “medical” and “social” models
49
Approach to Long-Term Care
Reform



IF human beings have mechanisms to
maintain physical, functional, and
psychosocial stability despite change
AND long-term care only partially
reflects that reality
THEN

We must ensure that care in all settings
respects and reflects—and does not impair
or damage—those balances
50
Approach to Long-Term Care
Reform



IF causes and consequences have
identifiable relationships, and those
links are important to identifying care
AND long-term care only partially
reflects this understanding
THEN

We must try to get care in all settings to be
based on identifying and linking causes
and connecting causes and consequences 51
Approach to Long-Term Care
Reform



IF biologically sound care provides
treatment in context and as a means to
an end, instead of an end in itself
AND long-term care only partially
reflects this understanding
THEN

We must try to get the care to be given in
the proper context
52