We Need Improved Coordination of Health Care
The Affordable Care Act — that lightening rod of American politics — remains the law of the land at least for now. We don’t know what Congress will do. But whether the ACA is eventually improved upon, repealed or left on life support, the law is more about health care insurance than health care delivery, although some of its provisions affect aspects of care.
Whatever happens to the law, one thing is certain: We need better coordination of our health care. As a long-time advocate for my husband, I have seen the need up close.
Medicine is fragmented. Specialists and sub-specialists are experts but often don’t have enough time to spend with their patients and may not communicate directly with one another, instead leaving notes in electronic health records. That can lead to gaps, overlaps, confusion and sometimes medical errors with serious consequences.
In the hospital the patient’s primary care physician is probably not involved in the case, replaced by a hospitalist — another specialist who likely doesn’t know the patient very well and whose role stops at the hospital door. Nurses all too often are overworked and understaffed, rushing from one patient to another to keep up with basic needs.
So who is coordinating our medical care? The question is a serious one. By one estimate inadequate care coordination costs between $25 — $45 billion annually. And that doesn’t take into account the toll on the patient in terms of suffering, prolonged illness, repeat hospitalization and more.
For older patients the problem is especially grim. A Harris poll released late last year showed that 70 percent of seniors rely on family or have no one to help them coordinate their health care needs. And in the critical months immediately following hospitalization, 63 percent reported that no one helped them coordinate their care. All of us should be alarmed by these findings.
Seniors aren’t the only ones in need of medical management, of course, but their needs are particularly pronounced as they have more illnesses, take more medication and may be less able to manage their own care. They also have more hospitalizations. Of the 35 million hospital admissions every year, seniors account for approximately 40 percent.
Being sick is bad enough. Patients and their families trying to cope with the medical bureaucracy often feel like tourists lost in a strange land where they don’t know the language, the culture or the customs.
Over the years, my husband has been hospitalized multiple times for serious, sometimes life-threatening, illnesses. I have no medical training but lots of experience working in bureaucracies, running interference and getting results. So I have become his de facto advocate, playing a key role working with doctors and nurses, participating in medical decision-making and often coordinating his care.
My husband says he is lucky to have me involved and playing an active role. And I suppose that’s true. But solving the problems of care coordination could help all patients benefit from the best that medicine has to offer.
There are decent efforts underway, but they tend to be limited. For example, professional hospital advocates can be helpful, so long as patients or their families know they exist and can call upon their services. Some facilities assign nurse navigators to help guide and advise patients. Others provide routine follow-up phone calls following discharge and even take the extra step of having nurses visit high-risk patients in person.
These steps are all good but far from universal. More advocates, nurse navigators and follow-up visits could help improve care coordination for many patients.
Here are four additional ideas I would like to advance:
· Require doctors to communicate directly with one another — in person or by phone — on a periodic basis when two or more are involved in patient care in the hospital or other facility. Notes in the electronic file are often cryptic, leave too much room for misunderstanding and are easily overlooked.
· Demand that hospitalists or attending physicians consult with primary care physicians when patients are admitted to and discharged from hospitals, nursing homes or rehabilitation facilities. And, add to that a requirement that, upon discharge, medical records must be shared immediately — within 24 hours.
· Strengthen discharge planning procedures when patients transfer from one medical facility to another or to home. Strong education, training and coaching for patients and families can increase their personal investment in follow-up care and help produce better results.
· Compensate doctors for the time they spend coordinating and consulting with one another on a patient’s behalf. If we want our medical professionals to do a better job communicating, we must provide incentives.
Critics may argue that these steps will cost hospitals and other facilities time and money. Others might claim that insurance companies and Medicare are already under pressure to comply with too many mandates. There is some truth to their charges.