HCM FPX 5310 Assessment 2 Systems and Ethics in Decision-Making

Systems and Ethics in Decision-Making

The continuum of care is an essential and integral part of healthcare services, particularly for the care of elderly patients for whom transitions between various care settings are critical. To fill gaps in patient care, effective collaboration between internal clinical teams and external Community-Based Organizations (CBOs) is key (Durfey et al., 2021). The role of partnership working within healthcare systems to ensure the achievement of the systems’ aims and objectives, particularly in relation to geriatric care, and the ways in which partnership working can enhance the care co-ordination, problem solving and ethical aspects of care are explored.

Relationships within a Healthcare System

Multiple internal and external partners are required to work together to care for geriatric patients in a continuum of care. Primary Care Physicians (PCPs), nurses, social workers and care coordinators are all critical clinical staff, inside the clinic. PCPs are pivotal in overall geriatric health, as well as continuity of care between various health services (Hung et al., 2021). The care coordinator and nurse monitor patient progress, assist with a smooth transition from one care setting to another, help patients find lines of communication for patient and support network needs, provide patients with a safe environment, and verify care provided is patient-centred. Social workers can help connect patients to the services they require and are an integral part of the team.

The Community Based Organizations (CBOs) that offer home health, transportation, and food assistance services are vital partners on the outside. CBOs fill in the gaps during patients’ transition from the hospital to home and help ensure that geriatric patients receive the needed care in non-clinical settings (Durfey et al., 2021). Furthermore, there were also shared partnerships with rehabilitation centers, assisted living facilities, as well as with skilled nursing facilities (SNFs), which are the necessary facilities to provide care beyond the primary care setting. These facilities help patients to continue their healthcare uninterrupted and to return to functionality, once hospitalized or after surgery.

Both partners have special abilities to do the job. The direct medical supervision and coordination of care transitions is provided by the direct medical care team that delivers this service in-house. Concerning the external aspects of care, CBOs and skilled care facilities have been continuing to provide geriatric patients with physical and social support to deal with the shared issues faced by geriatric patients with regard to physical and social problems after hospitalization (Balaban et al., 2020). Collaborate across care settings and prevent hospital readmission to provide a holistic, patient-centered approach to care through cooperation, both internally and externally.

Healthcare System as a Framework for Problem-Solving

The health care system is a key component to address complex issues, including gaps in the continuum of care. The components of its organizational structure enable collaboration across primary care and long-term care facilities. Indeed, healthcare systems as a whole, like electronic health records (EHRs), are frequently used for facilitating the exchange of patient information among health providers (Tiase et al., 2020). This technology enables timely communication between a primary care physician and a rehab center, leading to care coordination and a seamless transition from one facility to another. The edge of this system is its capability to align services across the different levels of care, thus enhancing patient experience.

In addition, value-based care models are naturally focused on outcomes and not volume, making a comprehensive continuum of care a natural fit. The latter is one of the accountable care organizations (ACOs) that incentivize health care providers to lower avoidable hospitalizations of older adults (Lin et al., 2020). This creates a framework of service delivery, a regulatory and financial framework that can motivate service improvements.

Ethical Questions Related to the Continuum of Care and Organizational Impact

Ethical issues like patient autonomy, equal access to resources, and the quality of life for geriatric patients should be studied carefully in designing a comprehensive continuum of care. A key ethical concern is the respect of patient autonomy and making decisions about care transitions (Simon, 2020). For example, geriatric patients may wish to age in place even in the face of more beneficial medical support provided by a skilled nursing facility. These preferences must be taken into account along with clinical advice, and sensitivity to patient preferences will be needed, as will a well-developed process of informed consent.

If these moral concerns are not properly attended to, the repercussions on the organization can be significant. The regulatory body or a patient advocacy group could do an in-depth investigation, and the organization might suffer a reputational or legal blow (Bitonti & Hogan, 2022). However, an ethical stance that focuses on a patient-centered approach can improve the organization’s reputation, cultivate community trust, and positively impact patient health, which can increase the sustainability and effectiveness of the organization.

Conclusion

Collaborations among healthcare providers, community services, and specialized care facilities are crucial to an effective continuum of geriatric care. These collaborations ensure seamless transitions and comprehensive patient support, and address ethical issues such as patient autonomy and equitable access to care. A clinical-social alignment of resources can improve patient outcomes, decrease the risk for hospital readmission, and improve organizational effectiveness in geriatric care.