I regularly share stories and worries with friends who have aging parents and in-laws. I know that I am not alone in wishing our health care delivery system was better connected.
Being a physician and administrator, I have been on multiple sides of this equation. As Physical Medicine and Rehabilitation specialist, I contributed to comprehensive care plans for patients returning home after problems including stroke, traumatic brain injury, and spinal cord injury. As I followed along with patients and their families it was eye-opening to see how realistic (or not) these plans turned out to be.
My career in medical informatics has been focused on improving access and exchange of critical information to support coordination across various settings and providers of care. The current limitations in these areas make the transition to value-based care models like ACOs difficult to impossible for many community health care systems. This is a chicken and egg problem.
Putting on my hat as son and son-in-law, I have some basic suggestions to my physician colleagues to improve care coordination for our frail elderly parents.
- When an older patient in your practice moves to another city, create a summary for them and their family that includes a narrative of treatment for the past 5 years for all their major problems. This is especially helpful for patients with dementia who are not able to provide accurate information. Wouldn’t it be great to receive one of these summaries for a new complex patient to your practice? Pay it forward.
- Prescribe 12 months of medications to ensure that the older patient does not run out of medications in their new city. This takes pressure off the family to find a new primary care physician just to get medications refilled. My mother-in-law was recently in this situation when she arrived out our home with less than 10 days of medications and no refills on chronic medications from her long-term primary care physician.
- Complete HIPAA privacy paperwork with family and other caregivers in the new city so they are able to receive medical records and support the transition to a new medical practice. It is common to wait for this as an older patient is being on-boarded to a new primary care practice. My personal and professional experience suggests this is too late and does not anticipate realities of going to urgent care and emergency care in the new city before being on-boarded to the new medical office.
These seem like basic procedures which could be implemented and align well with the principles of Patient-Centered Medical Home and Patient-Centered Data Home initiatives.
Todd Rowland MD, concerned son and son-in-law