Implementing the vulnerability concept in health and social care
In the Winter edition of AHHB, we discussed the idea of vulnerability, who is vulnerable and how being vulnerable potentially impacts on healthcare interactions and patient outcomes. In this issue, we explore how healthcare providers and ageing and disability services can utilise the vulnerability concept in their everyday work.
One of the highly practical features of the vulnerability concept we have outlined is that it is flexible. It addresses the complexities associated with individuals, groups, locations, situations and temporal features (eg, acutely urgent versus chronic and long-term). This makes it useful for systems which are themselves dynamic and whose clients are always changing in terms of their presentation, frequency or conditions.
Being able to focus on vulnerabilities allows the development of appropriate responses to the complexities of patients, clients and carers — and professionals. Assessing vulnerability in admission to a healthcare service, for example, means that we can examine the wider context in which those individuals are situated or even the supports from which they may now be separated.
Placing vulnerabilities
In areas such as an emergency department, an acute mental health setting or a homeless shelter we need to understand the situational nature of individual circumstances. Few people were always homeless, for example, and so some set of circumstances brought them to this point.
This is where a failure to get a good case history at admission, to plan well for discharge or a failure to follow up effectively often contributes to a cycle of repeat admissions to acute and crisis service providers. These patterns often affect a series of service providers who may not even know they are treating single dimensions of the individual’s overall context.
Vulnerabilities are complex, situational and dynamic. Thinking about people or groups as vulnerable, as though the vulnerability is simply a product of their being, is both wrong and unhelpful. We all know about clinical cascade effects but socially mediated vulnerabilities can have equally profound effects on an individual’s situation.
Part of the bigger picture is that places, like people, can produce vulnerabilities and that those places may also be contextual and temporal. By this, we mean that over time some places may recede as sites of vulnerability and new ones emerge. The risk of assuming vulnerabilities are permanent features of a person or location is that we may stop seeing changes as they manifest themselves and miss opportunities for intervention.
Context — chronic disease, comorbidity and multimorbidity?
We know that population ageing correlates with a rise in complex and chronic conditions. The concepts of comorbidity and multimorbidity, as well as longer-term conditions such as frailty, have emerged in the literature to address these growing situational and clinical complexities. This is because the traditional medical model focusing on a single disease no longer holds for a growing proportion of our population.
Older people frequently present multiple symptoms and intersecting underlying problems that need to be clarified before they can be adequately addressed. This is why geriatric medicine, for example, is gaining ground in health and aged care.
People with a disability are also likely to be in older cohorts but many people with pre-existing disabilities are living to older ages as care paradigms improve. So, we can see that personal and demographic complexities give rise to a growing range of clinical and systemic complexities.
The idea of vulnerabilities sits at the heart of this scenario, because our systems and services are in general designed to focus on a single issue or conditions. Complexity, either in clinical conditions or social circumstances, is not generally well handled. The difficulties in establishing truly integrated care, despite repeated calls and best efforts, attests to this underlying difficulty.
Assessing vulnerability
As a consequence of these various and often highly dynamic factors, we and our research partners are investigating how to operationalise the vulnerability concept in a variety of health and social care environments. This includes the need to be able to identify and action vulnerabilities on presentation at a service point. This involves understanding the social determinants of health, and looking for flags or indicators for the underlying causes and collateral effects of presentations.
Abuse, for example, is always a risk with people who are vulnerable, even if that vulnerability is temporary. The implication for us is that identifying vulnerabilities can assist in a number of key areas including patient/client safety, quality assurance, safe discharge to community (where relevant) and lowering inappropriate readmissions.
Other important considerations include onward referral to related service providers in a connected way that includes follow-up. People lost to follow-up often exhibit similar to increased vulnerabilities on subsequent contact. As we progress, we will report on developments in this area and the implication for different parts of the health/ageing/disability sectors.
Integrating vulnerabilities into systemic responses
One of the important themes in Australian healthcare in recent years has been domestic violence. This is a complex social problem with enormous impacts for individuals, mainly women, and their dependents.
Being subject to domestic violence can produce vulnerabilities where none existed previously. It can also exacerbate other situations that are themselves conducive to vulnerable status eg, homelessness, poverty, ill health, mental illness and so on. Knowing the situations faced by individual patients coming through the door on an Emergency Department, for example, adds to a holistic diagnosis of individual circumstance.
The issue then is identifying and integrating such vulnerabilities into the ways in which we provide care. The Rosie Batty story was one of missed opportunities to intervene in spite of multiple encounters with the healthcare system.
Assessment is obviously central to the initiation of a suitable intervention, but then there is the ‘case management’ coordination aspect that needs to be managed effectively. What decisions to make when? Which services are available to connect the person to? How best to do that? Taking responsibility for following up or ensuring coordination actually occurs across the pathway of care. And, of course, sharing the decision-making process so that the person has their say in all of this when at times they may be struggling to cope.
Conclusion
The crux of the matter is that every system we have is complex, from our social systems down to the smallest clinical service provider. These complexities have their own effects and people experience these contextually, not separately, making their personal circumstances deeply enmeshed in our systemic complexities.
This applies across the policy domains of health, ageing and disability — which are themselves much more deeply entwined than policy agendas often acknowledge. Knowing what to ask, how to respond and the implications of missed opportunities to intervene has implications for the client and our systems of treatment and care.
Our population is ageing, disability is on the rise and multimorbidity will become the norm. In this context, vulnerabilities will matter more than ever. Being aware of their potential impact and knowing how to incorporate their identification and effects into our health and social care systems can only continue to grow in importance. Integrating vulnerabilities into our technical, clinical and professional processes and practices will be essential.
| The UTS Visualising Vulnerabilities project is assisting the health, ageing and disability sectors implement and evaluate vulnerabilities across their organisation, to improve patient outcomes and reduce costs. If you would like to learn more about how a vulnerabilities program will benefit your organisation, and you would like to partner with a research institution, write to hamish.robertson@uts.edu.au. |
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