Health Care Integration

Introduction

This essay aims to discuss the topic of integrated healthcare and the multi-disciplinary care of a patient with severe acne vulgaris. The concept of integrated healthcare will be discussed, followed by a description of the condition acne vulgaris. This will be followed with an insight into the roles of the General Practitioner (GP), the Dermatologist and the Naturopath as a multi-disciplinary approach to the treatment of the patient.

This essay will discuss why healthcare integration is desirable, focusing on why a well-connected and integrated multi-disciplinary health care approach is more likely to succeed than a fragmented approach. It will also explain the potential problems caused by poor integration of services, as well as explaining the benefits of integration when properly executed.

Integrated Health care

Australia and New Zealand are known to have health care systems that generally deliver a high quality of care and positive outcomes for patients, however according to a discussion paper released by RACP (Royal Australasian College of Physicians), there is potential for fragmented delivery of services with lack of coordination. Insufficient integration of services potentially leads to gaps in patient care, inconsistent advice or treatments and wastage of resources (RACP 2018). For a patient who requires multiple disciplines to address their health issues, a lack of service integration will mean possible difficulties navigating between services and problems accessing timely and appropriate care (RACP 2018). The RACP believe there needs to be reform to health policy to improve the integration of health care delivery to advance the quality and safety of services and to overcome inequities in healthcare. This would require less hospital-centric services and a combination of improved access to services regionally and improved communication and collaboration between disciplines for a patient-centred system. To help facilitated integrated care, shared electronic records have been introduced in both Australia and New Zealand aiming to provide access of information and collaboration to the various streams of the healthcare system (RACP 2018).

Example Patient: Acne Vulgaris

Acne Vulgaris is a chronic inflammatory skin disease featuring excessive production of sebum (seborraea), altered keratinisation and bacterial colonisation by Propionibacterium acnes, which affects the pilosebaceous follicles of the patients’ skin (Al-Hammadi et al 2016). The skin presents with open or closed comedones (blackheads and white heads) and a variety of inflammatory lesions. These inflammatory lesions include papules, pustules or cyst nodules which are mainly seen in high grade acne considered as cystic acne) (Zaenglein, A. et al. 2016, Bhate and Williams 2013, See, J. 2015).

The patient to be addressed in this essay is a young adult female with a darker skin type of Fitzpatrick V (Aprans n.d.). She is in her early twenties and suffering from a high grade of pustular acne vulgaris (Appendix 1). Acne vulgaris is an extremely common skin disease, most commonly affecting young patients, in fact eighty five percent of patients that present with acne vulgaris condition are teenagers and young adults (Zaenglein, A. et al. 2016, See, J. 2015).

Bhate and Williams (2013), estimate approximately twenty percent of young people have acne vulgaris ranging from moderated to severe, with severity correlating with puberty. The association of ethnicity and acne is currently uncertain, however darker skinned individuals are more disposed to post inflammatory hyperpigmentation (PIH) as a result of acne induced scarring (Appendix 2). Acne will generally appear on the face, neck, back and chest as sebaceous glands are most active in these areas. The precise cause of acne vulgaris is unknown (Al-Hammadi 2016), however according to Dr Jo-Anne See (2015), from the Australasian College of Dermatologists, the main causes are hormonal, blocked sebaceous glands, bacteria and inflammation, genetics, stress and diet.

Acne vulgaris also has the potential to negatively affect quality of life for the patient due to the possibility of causing psychological and social complications as a result of the physical and emotional impact, exacerbated by a lack of integrated services (Hanna et al 2003). Factors influencing the non-dermatological aspects of acne are personality, age, and social/cultural factors, as well as the specific acne characteristics (duration, severity, scarring) (See 2015). A patient with this severity of acne vulgaris would typically present first to their General Practitioner (GP), and if deemed necessary, the physician would refer them on to other disciplines for further assessment and treatment.

Health care disciplines for the patient with acne vulgaris

General Practitioner

General practitioners (GP) are primary health care physicians, the first, or ‘primary’ choice of contact when seeking medical advice. The GP assesses, diagnoses and treats a wide range of conditions, illnesses and injuries and refers on to specialists when required as per the patients’ requirements (RACGP, n.d.)

For a patient with acne vulgaris, the GP will diagnose the severity, or ‘grade’ of acne and possibly prescribe topical or oral medications to address the patient’s condition. If the acne is deemed severe, the GP may refer the patient to relevant specialists such as a Dermatologist for further oral and/or topical medications and possibly skin treatments such as skin needling, chemical peels, injectables and laser skin resurfacing. The GP could also refer this patient on to a naturopath for gut health and diet, if deemed appropriate, as a multidisciplinary approach to patient care. For this paper the example patient with acne vulgaris is assumed to have been assessed by the GP. Her condition has been diagnosed as severe and chronic acne vulgaris, that she has a diet high in processed sugars, carbohydrates and saturated fats, thus the GP has referred her to a Dermatologist and a Nutritionist/naturopath with the aim of integrated care.

Dermatologist

Dermatologists are physicians that specialise in the diagnosis, treatment and prevention of all skin conditions (including hair and nails), in addition to surgical procedures. They also offer cosmetic services, such as cosmetic injectables and laser.

For the treatment of acne vulgaris, the dermatologists can prescribe topical retinoid creams (Vitamin A) to increase cell turn over, oral contraceptive pill (OCP) to address hormonal cause, antibiotics to kill bacteria, or isotretinoin (Accutane). In addition, they can perform a series of chemical peels (glycolic and lactic acid) and laser skin resurfacing over time to help reduce the appearance of scarring and pigmentation resulting from severe acne (Al-Hammadi et al 2016) (Appendix 3).

Naturopath

Naturopathy is a form of holistic care, focusing on the treatment of the body and mind as a whole, promoting general wellbeing to minimise any symptoms that may arise, and to prevent any future illnesses. (BetterHealth n.d) Naturopaths provide complementary, science-based therapies including nutrition, homeopathy, herbal medicine, flower essences, counselling, massage therapy, Vitamin and mineral therapy and aromatherapy. (Stainton, R. 2016) From a naturopathic viewpoint, acne is an external manifestation of an internal imbalance. As with many naturopathic treatments, nutrition is key to treating acne due to the sebaceous glands secreting sebum made from the fats that are eaten. If poor quality fats (saturated fats, trans fatty acids) are eaten, the body produces poor quality sebum. If good quality fats (olive oil, fish oil, flaxseed oil) are eaten, the body produces good quality sebum. Poor quality sebum does not flow adequately, clogging the pores and therefore creating pustules due to the blockage. (Swierzewski, S. 2015). According to Bowe et al (2010), Dermatologists can no longer dismiss the association between diet/nutrition and acne. It is stressed that convincing evidence exists that show high glycaemic load diets may exacerbate acne. Dairy consumption appears to have a possible association with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A and dietary fibre remain to be clarified.

Benefits and desirability of a well-integrated health care system

As previously discussed, the integration of healthcare refers to the multiple healthcare disciplines communicating to assess, diagnose and treat a patient who may benefit from a multi-disciplinary approach to their care. Although there can be no one specific approach to integrated care that will meet the needs of all patients, integrated healthcare in Australia aims to create a holistic approach that has an effective and efficient outcome, that centres around the patient, using funding appropriately to attend to the needs of the community which makes it so desirable. Integration of Health services makes receiving multiple different care services, such as a GP, Dermatologist and Naturopath for the acne vulgaris patient, a smoother transition between disciplines which is beneficial for both the patient and the health care providers (RACP 2018, DOH 2018)

As the different specialties and experience held by each professional can view a client from different viewpoints, a wider variety of options for the patient along with multiple treatments to help the patient are then available. For the acne client this is desirable as while the GP and Dermatologist are focused controlling and treating the acute acne outbreaks or treating the scarring and pigmentation issues once the acne is under control, the holistic and nutritional approach of the naturopath may be helping to prevent the occurrence or recurrence of the acne. In response to the consequences of poor communication between Health care professionals Blom et al (2015) devised a model of care named SBAR (Situation, Background, Assessment and Recommendation) to facilitate effective communication. They found the introduction of SBAR increased the experience of having a well-functioning structure for communication amongst health care professionals regarding the patient’s condition.

Potential difficulties

Whilst it is most beneficial to have a well communicating and integrated health care approach, this does come with complications. The complex nature of healthcare in Australia can make integrated health care difficult to deliver. Poorly integrated health services can create fragmented healthcare which contributes to higher rates of hospitalisation, ER presentations and medication errors that could have been avoided (RACP 2018).

Various health disciplines can provide different or contradictory advice. Although it is beneficial to have multiple approaches and perspectives in healthcare, if this is incorrectly managed crucial misunderstandings, disagreements, conflicting advice and bias can occur. This consequently is a hinderance to safe and effective patient care. The different approaches and disciplines, backgrounds and experience can result in opposing opinions and create confusion and non-compliancy in the patient (Frimpong et al 2017, RACP 2018).

A difficulty could arise for the example patient with acne vulgaris due to contradictory advice being given via Dermatologist and Naturopath, also if there are multiple providers focused on one patient, there is room for error not only in communication but smooth collaboration of services, which could be a contributing factor to medical error and claims of malpractice (Frimpong et al 2017, RACP 2018).

Conclusion

If measures are taken to address the fragmented healthcare that can result from poor integration and communication between healthcare providers, then healthcare integration can beneficial to both the health care system and the patient. For patients being treated by multiple healthcare professionals, open communication needs to be prioritised, with integration encouraging the collaboration of various health professions. The digital integration of patient records will assist with this issue. Healthcare professionals will be more likely to acknowledge and appreciate the different perspectives that other health care professionals can offer, opening channels of communication and the sharing of knowledge and information.

Various complementary medicine approaches have been researched and introduced and are having an important role in management of acne where the conventional and standard treatment cannot be utilised. However, their recommendation for treatment is limited by lack of large-scale studies and evidence about their efficacy and safety profile. Further large clinical trials comparing these new treatments with existing treatments will be necessary in the future along with integrated patient care and evidence-based treatment.