A tsunami threatens to flood the U.S. healthcare system. The arrival of baby boomers into Medicare has been called a silver tsunami, and it’s certain to affect how healthcare providers serve their patients across the healthcare continuum.
The delivery of continuity of care through a person-centered care model promises to impact how patients are served throughout the care process, how physicians and patients interact going forward, and how compensation is awarded.
As provider compensation is increasingly tied to outcomes with value-based care, the active role of primary care physicians (PCPs) along the care continuum is also evolving. This is uniquely the case for those PCPs who serve geriatric patients, especially those with patients entering skilled nursing facilities (SNFs).
The move into a SNF is often a dramatic transition in a patient’s life. Yet, it is just one phase in a patient’s healthcare continuum that a PCP must monitor in order to enhance patient care and improve health outcomes.
Continuity begins with smooth transitions
Independent physicians and, in fact, all healthcare providers, who are serving the growing senior population must recognize the importance of a smooth transition for senior patients entering SNFs. It is to the benefit of their patients, their families, and their providers that this adjustment is as seamless as possible.
The rapid increase in the senior population will send shock waves to the healthcare system for years to come as they need extra—and extra expensive—care. The number of Americans aged 65 and older will double to 71.5 million by 2026. According to statistics from the Florida Healthcare Association, among those turning 65, almost seven in 10 will need some form of intensive or long-term care.
The solution on how to manage these patients may lie in an exerted effort to provide continuity of care. Numerous studies show that continuity of care results in better outcomes: healthier patients, reduced incidence of complications and medical costs, and fewer hospital visits and admissions. Today, more than ever, PCPs must be better versed in caring for seniors and the specific challenges they face.
Life transitions are difficult for most people. Physicians must take into account how disruptions in a senior’s life can be more dramatic and have long-lasting effects on their health. Transitional care coordination is vital. Independent physicians looking at a patient in his or her entirety should consult with hospitalists, nurses, and social workers who help coordinate from acute to post-acute care as well as family members who can provide insight into the patient.
Similarly, physicians must maintain steady contact with the patient, family, and other care professionals who are helping smooth the transition. Communication right from the start is key.
Sharing vital patient data is an essential component of how PCPs interact with a myriad of professionals, including hospitalists, hospital administrators, specialists such as neurologists or cardiologists, and SNF staff. Having this information easily accessible and knowing how you want to be notified patients’ health changes will further enhance communications and patient care.
In a report on continuity of care, pharmaceutical company Merck & Co. noted that “all people involved in a person’s healthcare, including the person receiving care, [must] communicate and work with each other to coordinate healthcare and to set goals for healthcare,” to achieve excellent outcomes. “When continuity of care is missing, people may not adequately understand their healthcare problems and may not know which practitioner to talk to when they have problems or questions.”
