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The financing and provision of health care in the United States is distributed across many distinct organizations, each with its own objectives, obligations and capabilities. These fragmented organizational structures produce disrupted relationships, inadequate information flows, and misaligned incentives that combine to degrade the quality of health care and increase costs. This chapter analyzes the causes and consequences of organizational fragmentation in the health insurance and care delivery systems. It also assesses the ability of modern information technology to mitigate the costs of fragmentation by enhancing coordination across organizations.

Chapter 1 highlights how important it is for hospice social workers to operate as champions of spiritual care with and on behalf of their patients. This begins with exploring why it is important to understand a patient’s experience of spirituality. Spirituality is described as having significant implications for life quality and delivery of hospice care Hospice social workers are essential members on interdisciplinary teams charged with the responsibility of ensuring patient access to quality hospice care, which for some patients necessitates spiritual care. To lay the foundation, hospice social workers need to understand how to engage in spiritually-sensitive hospice social work so they have the capacity to coordinate, if not deliver, spiritual care.

Chapter 8 suggests that social workers can evaluate spiritually-sensitive hospice social work by drawing from models of spiritual competence. Evaluation in the practice setting is essential to ensure that patients experience hospice social work as being spiritually sensitive, rather than spiritually insensitive or, even worse, spiritually destructive. This chapter presents several models of spiritual competence with a focus on Hodge (2011) and associates (Hodge & Bushfield, 2006; Hodge et al., 2006) to evaluate spiritually-sensitive hospice social work. Such evaluation not only reflects the importance of understanding the spiritual quality of hospice social work, but the need to ensure that hospice social workers have the necessary spiritual competence. This includes assuming leadership in sensitizing interdisciplinary team members to patient spirituality.

The nurse is a generalist who needs the ability to be all things to all people at an ALS centre and must have the qualities of flexibility, creativity, warmth, empathy and more, acting as a specialist practitioner, manager, counsellor, coordinator, educator, supporter, researcher, mentor, and innovator. The nurse has an essential role in the support of the person with ALS, their family and the other members of the multidisciplinary team.

This concluding chapter argues that, although created as a solution to physician scarcity, the nurse practitioner (NP) is just as often working on the front lines of the care crisis. The Forest Grove Elder Services ostensibly hired its NPs for their medical expertise, but in practice, it deployed them as much more than substitute physicians. In addition to the mandates of medical work, the Grove held its NPs uniquely responsible for care coordination. Ultimately, the NPs' performance of organizational care work had become the cornerstone of the Grove's goal of comprehensive care provision. Yet it was equally clear that the work and expertise required to meet this goal were largely unacknowledged. Indeed, NPs' work often goes unrecognized, but their performance of it has the potential to transform how patients experience the health care encounter. The chapter then suggests that NPs are often not doing the same work as physicians. In this account, the aim is not only to reveal the hidden work of yet another location of feminized labor but also to shine a light on the central importance of that work for patients.

Health care reform through the Affordable Care Act in the United States contained specific measures to encourage rapid reform in the way that physicians are compensated, moving away from the historical norm of fee-for-service payment to global payments to existing or new “accountable care organizations” (ACOs), combinations of hospitals, and physician groups. The shift to ACOs is intended to bring greater coordination to care while changing the underlying financial incentive for physicians so that they are rewarded for prevention of illness and for more efficient, less costly care overall. Questions remain about how the global payments to large ACOs will be translated into incentives for individual physicians working within these organizations. This chapter emphasizes that the term “bedside rationing” obscures the important distinction between the random variation in rationing possible across individual physicians and a more organized approach to making allocation decisions and treatment guidelines for the population cared for by a physician organization.