Health Systems Issues and Strategic Planning for Elderly Care

Introduction

The delivery of high-quality healthcare services requires a sophisticated health system infrastructure that provides a multidisciplinary team approach. This infrastructure varies from country to country, but there are common features that characterize health systems and can be used to identify best practices and current trends in healthcare delivery and administration — both in general and for an elderly American patient in particular. As the United States becomes an increasingly multicultural society, there will be a growing need for informed and culturally sensitive approaches to healthcare delivery. There will also be an increasing need for health systems that provide the range of services required by the elderly.

This paper identifies health systems issues for a typical elderly American patient, including a review of relevant peer-reviewed and scholarly literature and an analysis of the implications of these issues for health systems. A strategic plan for addressing these implications is followed by a summary of the research and key findings in the conclusion.

The provision of public health services is defined by Bagley and Lin (2008) as "the organized response by society to protect and promote health, and to prevent illness, injury and disability" (p. 721). Health systems are therefore the framework by which the delivery of healthcare services is accomplished. As Bagley and Lin point out, "Without a 'system,' there can be no 'organized response'" (2008, p. 721). According to Sarisky and Gerding (2011), the need for efficient health systems has never been greater, and demand for healthcare services is projected to increase significantly in the coming decades as a result of an increasingly elderly population that will require an enormous amount of health support. In this environment, identifying efficient and effective health systems has assumed new relevance and importance (Sarisky & Gerding, 2011).

Defining Public Health Systems and Performance Criteria

Moreover, a wide range of market factors are affecting the manner in which healthcare is organized, delivered, and financed (Myers, Paulk, Dudlak, & Mehlman, 2001). According to these authorities, "While the cumulative effect of these market forces is difficult to predict with certainty, we believe that the collection of these forces will transform healthcare from a 'seller's market' (e.g., provider driven) to a 'buyer's market' (e.g., consumer driven). As in other buyer's markets, the basis of competition increasingly will be to offer products and services that are better, faster, and/or cheaper than the competition" (Myers et al., 2001, p. 3).

From a public health system perspective, the U.S. Department of Health and Human Services defines the public health system as "the complex network of organizations that work towards fulfilling the public health mission of assuring conditions for a healthy population" (cited in Sarisky & Gerding, 2011, p. 25). Although health systems vary from country to country, all countries have a mixed health system characterized by a significant governmental presence (Hoggett, 2003). To help develop criteria for evaluating the performance of different health systems, the World Health Organization (WHO) has formulated a series of criteria that focus on various aspects of performance (Wallace & Villa, 2003).

The WHO reports that effective health systems share several common characteristics, chief among them the ability to provide quality healthcare services to everyone in need. According to the WHO, "The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies" (Key components of a well functioning health system, 2010, p. 1). Other common characteristics of well-functioning health systems include:

1. They improve the health status of individuals, families, and communities;
2. They defend the population against what threatens its health;
3. They protect people against the financial consequences of ill-health;
4. They provide equitable access to people-centered care; and
5. They make it possible for people to participate in decisions affecting their health and health system (Key components of a well functioning health system, 2010, p. 1).

Just as it is impossible to isolate a single most important factor in the provision of high-quality educational services, it is also impossible to single out any one key component of a high-quality health system. However, it is possible to identify those key components that typify a well-functioning health system, as set forth in Table 1 below. To help guide implementation, the WHO has published a set of quality indicators for well-functioning health systems that can be used to formulate elderly- and site-specific goals and target dates for completion — a process consistent with health system development over the past several decades (see Appendix A).

Table 1: Key Components of a Well-Functioning Health System

Leadership and governance: Each country's specific context and history shapes the way leadership and governance are exercised, but common ingredients of good practice can be identified.

Health information systems: Good governance is only possible with good information on health challenges, on the broader environment in which the health system operates, and on the performance of the health system.

Health financing: Health financing can be a key policy instrument to improve health and reduce health inequalities if its primary objective is to facilitate universal coverage by removing financial barriers to access and preventing financial hardship and catastrophic expenditure.

Human resources for health: The health workforce is central to achieving health. A well-performing workforce is (a) responsive to the needs and expectations of people, and (b) fair and efficient to achieve the best outcomes possible given available resources and circumstances. Common concerns include improving recruitment, education, training, and distribution; enhancing productivity and performance; and improving retention.

Essential medical products and technologies: Universal access to healthcare is heavily dependent on access to affordable essential medicines, vaccines, diagnostics, and health technologies of assured quality, used in a scientifically sound and cost-effective way. After salaries, medical products are the second-largest component of most health budgets and the largest component of private health expenditure in low- and middle-income countries.

Service delivery: Health systems are only as effective as the services they provide.

Source: Adapted from WHO Factsheet: Key components of a well functioning health system (2010).

As Table 1 illustrates, the quality of leadership and governance are essential considerations in healthcare delivery. This is congruent with the body of literature, which indicates that leadership "is a critical element," but that "there is significant unresolved debate about what leadership is and does, and how the leadership ability of individuals might be predicted and enhanced" (Bagley & Lin, 2008, p. 722). With respect to health system financing, Arnett (2010), a private hospital CEO, reports that "cost reduction has been moved to the top of priorities in most healthcare institutions" (p. 37). Clark, Savitz, and Pingree (2010) also emphasize that "opportunities exist in many hospitals and health systems to consistently provide an extraordinary patient care experience while reducing operating costs" (p. 20). This approach requires an ongoing, vigorous top-down emphasis on adding value and eliminating waste at every opportunity. Clark and his associates note that "recognizing and appreciating that structure follows strategy, the organization that builds a continuous learning and performance improvement culture is in a better position to design an organizational structure that sustains progress toward clinical and operational improvement goals" (p. 20).

Health Systems for the Elderly

These are substantial challenges for the healthcare community and policymakers alike. According to Conrad and Shortell (1999), there remains serious debate concerning which health system model is best suited to address the changing needs of American society and its elderly population. Just as innovations in information and telecommunications technologies have fundamentally changed the way patient data is collected, analyzed, and acted upon, mergers and consolidations of hospital chains have also created new operational capacities that affect the elderly — issues discussed further below.

According to Kim, Miller, and Schofield-Tomschin (1998), advances in modern medicine mean that babies born today have a 50-50 chance of living to age 100. The more immediate concern for policymakers, however, is that 75 million baby boomers reached their 65th birthday in 2011, marking the beginning of a wave of elderly population growth. There are notable gender- and race-related differences within this elderly population that will affect the optimal type of health system needed by mid-century, as shown in Table 2 below.

Table 2: U.S. Life Expectancy in Years

Life Expectancy at Birth: 1970: 70.8 | 1980: 73.7 | 1989: 75.1 | 1990: 75.4 | 1996: 76.1
Men: 1970: 67.1 | 1980: 70.0 | 1989: 71.7 | 1990: 71.8 | 1996: 73.1
— White Men: 1970: 68.0 | 1980: 70.7 | 1989: 72.5 | 1990: 72.7 | 1996: 73.9
— Black Men: 1970: 60.0 | 1980: 63.8 | 1989: 64.3 | 1990: 64.5 | 1996: 66.1
Women: 1970: 74.7 | 1980: 77.4 | 1989: 78.5 | 1990: 78.8 | 1996: 79.1
— White Women: 1970: 75.6 | 1980: 78.1 | 1989: 79.2 | 1990: 79.4 | 1996: 79.7
— Black Women: 1970: 69.4 | 1980: 73.6 | 1989: 74.9 | 1990: 75.2 | 1996: 76.1

Source: Baum, Jennings, & Manuck, 2000, p. 29.

Community-based health systems will represent an increasingly important element in the provision of healthcare services for the elderly, and there are best-practice models available in the literature to help guide the implementation process (Roemer, 1999). By establishing quantifiable goals and target dates for implementation, healthcare providers can fine-tune their approaches to optimize outcomes, maximize the return on investment of scarce healthcare resources, and help elderly consumers remain independent for as long as possible (Roemer, 1999). This goal is congruent with the observations of Tobin and Lieberman (1996), who emphasize that "current social and health services are generally more economical to deliver through the community than through long-term care institutions. If health systems for the elderly were more efficient, institutionalization could be warded off for many more people and could be offered more selectively" (p. 245).

One notable gap in the body of knowledge concerns a lack of consumer perspective regarding which outcomes are most desirable. Even in situations where long-term care becomes necessary, there is little evidence available concerning optimal institution size, as most facilities are large — approximately 180 beds is considered most efficient by most standards (Tobin & Lieberman, 1999). As noted in Table 1, one of the key elements of a well-functioning health system is the quality of human resources. By providing long-term care in smaller facilities, the elderly would be better positioned to receive the individualized care they need. According to Tobin and Lieberman, "An optimal size, from the perspective of the resident, however, is much smaller than 180. Small institutions could be efficient if professional expertise of a wide variety of types were used to develop and coordinate the delivery of diverse, high-quality services" (p. 245).

Conclusion

The research showed that national health systems vary from country to country, but the elements of a well-functioning health system include solid leadership, modern health information systems, adequate health financing and human resources for health, as well as provision for essential medical products and technologies and the service delivery required by a multidisciplinary team approach to healthcare. Taken together, the optimal health system for elderly Americans can be regarded as one in which the needs of the individual healthcare consumer are paramount, irrespective of costs involved.