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How to provide continuity of care for older patients


With the silver tsunami fast approaching, it’s critical that physicians develop workflows to keep abreast of seniors’ health amid anticipated life changes and transitions of care.

seniors, baby boomers, silver tsunami, continuity of care, care transitions

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.”

It takes a (digital) village

Staying informed is vital to establishing continuity of care and a patient-centered care model. Fewer independent doctors have hospital privileges and are making rounds, meaning hospitalists are left to care for seniors who are admitted to the hospital. This means the tending doctor does not know if or when the patient previously visited the emergency department, whether the patient was admitted to a hospital, or if the patient lives in a SNF. The doctor is now also at the mercy of the patient or patient’s family to provide records following the hospital visit or admission.

That presents a health risk-and an opportunity for improvement. Here are five strategies to bolster the role information sharing for better care coordination:

Ask for updates. Communication is critical, and increasingly so, as healthcare continues to operate in individual silos. For each patient visit, PCPs and their staff should actively request updates from the patient, family, caregiver, or healthcare surrogate on recent changes in patient medication and history, including hospital visits and use of telemedicine or telehealth services.

Build relationships with hospitalists and SNFs. Unfortunately, PCPs may not always receive vital updates from specialists, SNFs, or family members. To the best of your ability, engage hospitalists and area SNFs about patient activity and how to improve information sharing.

Add EHR alerts. Not all practices or providers share electronic health records (EHRs). If your practice uses EHRs, inquire with your technology provider about prompts or the ability to be notified of patient status updates, particularly after visits to specialists or hospital admissions.

It’s also important to note that long-term care providers were not incentivized in the same manner as hospitals and other providers to adopt EHRs through HITECH Act, so their adoption of and adjustment to electronic delivery of records is still in its infancy compared to other healthcare sectors. You may need to devise additional strategies to stay abreast of patient status updates.

Encourage your patients to keep you updated. Send patients home with literature after each visit encouraging patients and their families to keep you informed. Establish your expectations regarding sharing of patient information-be it a visit to the emergency department, walk-in clinic, specialist, move to a SNF, or a change in medication. Explain what you want to know, why you want to know it, and how this information will ultimately help the patient. It can’t be underestimated how informed PCPs can anticipate needs, elevate care, and reduce bounce back into the acute care or rehabilitation system.

Avoid complacency. Make continuity of care an internal gold standard. With the growing use of accountable care organizations, PCPs will see demands for quality, efficiency, and outcomes rise. The sharing of information must be that gold standard at your practice. Collaboration and sharing of information will certainly result in an increase in these metrics.

PCPs who care for older patients can avoid the communications chasm and better prepare for the tsunami, silver or otherwise, by examining the whole patient and communicating with the patient and other healthcare providers.

Gregg Clavijo-Hopper is COO and senior vice president of post-acute services at Greystone Health, a Florida-based provider of owner-operator skilled nursing facilities and home health agencies offering a full continuum of care for both patients and referral sources.

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