Discontinuous care often means that no single health professional takes “ownership” of a patient’s health as a whole

Dr. Erin Kane, an emergency physician on faculty at Johns Hopkins, described to us what this endless cycle means in reality. A patient will go to see their primary care provide (PCP) for a particular reason, the PCP will refer the patient to a specialist or to the emergency room depending on the issue, and then the specialist or emergency room admitting team will discharge the patient to follow up with the PCP with regards to the exact challenge that led the patient to seek care in the first place. Dr. Kane gave this example to illustrate that each stakeholder in this cycle simply acts by filling their particular role in the health system, often with the goal of discharging or referring the patient as quickly and efficiently as possible. All too often, what this means is that no provider ever actually takes “ownership,” to borrow Dr. Kane’s word, over the patient’s health overall. There is no case manager, no one person accountable to make sure that patient receives the best care as a complete unit, meaning that the patient instead experiences a disjointed collection of care fragments.

Ownership certainly does not mean that any one health professional, or even any one practice, needs to be responsible for delivering all the care for a patient. Rather, it means that a patient needs someone to be accountable for ensuring that the various providers that a patient might see combine to meet the patient’s needs, rather than just checking their individual boxes and then passing the patient off. This idea of ownership is an individual-level display of the concept of value in care, ensuring that the ultimate outcome is not a series of services, but rather a complete and effective package for support for the patient.

Patient-centered care means that patients themselves should be equal participants in decisions made about their healthcare. Many experts shared the sentiment that there are two experts in every health interaction. One is the provider(s) who is an expert in the medical aspects of the disease and can communicate about risks, symptoms, and treatment options. The other, however, is the patient, who is the expert in their experience with the disease, and along with that their priorities, goals, and capabilities. Effective care is that in which the treatment options offered by providers align with, and are decided in conversation with, the patients and their priorities. Often, it may take many members of a care team to understand and support a patient’s priorities, and the physician may not always be the best suited to lead this conversation based on expertise and time limitations.