For seniors trying to manage multiple chronic disease, moving from one care setting to another can literally be a matter of life and death. That’s why it is so important that health providers–doctors, nursing homes, hospitals, assisted living facilities, and home care agencies–work together to make sure that those moves happen safely.
Too often in our poorly coordinated health and long-term care systems, those transitions fail: Somebody loses track of a medical record, fails to correctly administer an important medicine, or repeats an unnecessary, costly and uncomfortable test. Transitions even within hospitals are notoriously dangerous. When they require cooperation of different providers, the risks are even greater.
Transitional care was the subject of the Gerontological Society of America’s annual meeting this week in New Orleans. Just the fact that physicians, social workers, nurses, and academic researchers spent five days talking about this topic was hugely important. It is evidence that the issue is finally getting the attention is deserves.
Even better news: There are transitional care models that both improve patient health and save money. New training programs are making doctors, nurses, and aides aware of the importance of careful transitions and teaching them how to better accomplish them. Other programs work with families to help make them strong advocates for patients during these challenging moves. And models such as those developed by Eric Coleman at the University of Colorado, Mary Naylor at the University of Pennsylvania, and Chad Boult at Johns Hopkins University, have all redesigned the systems we use during transitions.
At the same time, old models are being improved. Palliative care programs do a great job combining medical treatment with social and spiritual care as well as symptom management to improve outcomes for patients. But now they are being better integrated into hospitals and physician practices–a key element to their success.
On the other hand, it was clear how far we have to go, especially in our wildly inefficient fee-for-service health system. Discharge planning in both hospitals and nursing homes continues to be a broken link in the chain of care. Too often, patients are sent home or to a nursing facility without an appropriate care plan in place. Discharge planners are overworked and ill-prepared, and too often the focus is on a quick discharge rather than a good plan.
In addition, while many creative experiments are sprouting up all over the country, it was clear from listening to researchers that we have a lot to learn before we know which will work and which will disappoint.
On December 13 and 14, I’ll be participating in an important conference in St. Louis on ways to better integrate care for chronically ill seniors. Sponsored by the Catholic Health Assn., the program will bring together health providers to share successful ideas and help work though some of the financial and medical challenges to better coordinating care.