We Need to Connect Medical and Social Care for Seniors

Eighty-give percent of physicians say that unmet social needs lead to worse health outcomes, according to a new survey sponsored by the Robert Wood Johnson Foundation. But only 20 percent are confident in their ability to help patients and their families meet those needs. Talk about good news and bad news!

The survey asked about a wide range of social services from employment assistance for younger, low-income patients to transportation and food assistance, the kind of help that is often critical to the frail elderly living at home. But whatever the assistance, it seems beyond the abilities of doctors to even to tell their patients and their families where they can get it.

This is not a surprise to seniors or their family caregivers. Too often, even primary care physicians are on an island when it comes to patient care. Too often, they see their job only as providing a medical solution to a specific complaint. But when it comes to helping a patient cope when she goes home, too many doctors are clueless.

This is a particular problem with the frail elderly who often suffer from multiple chronic diseases and may need personal assistance as much as medical treatment. Doctors often have no idea whether a patient with severe arthritis must climb stairs when she returns home. Similarly, physicians rarely know whether a patient with diabetes has access to proper foods or whether someone recovering from a stroke has transportation to her physical therapy appointments.  And most often, docs have no idea whether their patients can manage complex medications.  

It is easy to criticize physicians for their lack of knowledge and attention. But rarely are they trained to address these issues. And neither Medicare nor most insurance plans pay them to even ask about these critical needs, much less connect patients to people who can help.

Three of four docs surveyed said the health system should reimburse the expense of making those links.  But it does not.

A few practices, some using the patient-centered medical home model, do address this gaping hole in the system of care. Nurse practitioners or physician assistants sometimes do help patients with making lifestyle choices and meeting social care needs. As medical homes catch on, we may see more doctors able to help where, as this survey shows, they recognize a real need.  

For many patients, it wouldn’t take much. A few words of advice and a simple flyer that identifies local resources (with phone numbers and Web addresses) would do wonders. Letting patients know what caregiver support groups are out there, what information and referral services are available, or providing a list of local care managers would be immensely helpful. And they’d cost the doctor next-to-nothing.  

Going a step further, providing coaching or direct care management services would make all the difference for frail elderly patients. The American College of Physicians has long recognized the importance of primary care practices providing case management to chronically ill patients.

Provisions of the 2010 health reform law such as Accountable Care Organizations and various integrated  care models may encourage docs to take on this role. New rules that will penalize hospitals for excessive readmissions may provide financial incentives for medical systems to support better care management.

The good news from this survey is that most doctors recognize the need. Now, they need the right incentives and some training to make it happen.

By | 2011-12-28T17:24:44+00:00 December 28th, 2011|Aging, Care Coordination, Health reform|9 Comments


  1. Shannon January 6, 2012 at 1:18 pm - Reply

    Howard, what a great article with such true points. It is fascinating how disconnected our current healthcare system is from eldercare resources. When we helped form a Falls Prevention Coalition in our local area in Florida, it was one of the benefits that came out of the meetings. For example, the local ambulance service got the most calls for falls, and often those people didn’t even end up being transported to the hospital…but here was a clear case of a point of contact being made where some info. and resources could be valuable. Even the small change of giving them some fall prevention materials and the local senior resource guides to hand out was a big step in the right direction.

    I like that your article brings awareness to this. I think for family caregivers esp. it will come as a surprise how little most of the docs they encounter provide or would even know if asked about local senior care resources. Not always the case, but it’s just typically not on the radar. As you point out, we don’t have things set up to encourage that, despite the desire to help, as it stands now.

    Whenever we’re working with a patient (since as care managers we usually attend Dr. appts), docs tend to get excited when they find out our role and seek info. for other patients. They realize the value of care continuity, someone to coordinate services and assess the patient in his/her home environment on an ongoing basis.

  2. diane chau md January 25, 2012 at 5:10 am - Reply

    Clearly the survey respondents were not all geriatricians. Geriatric medicine training would povide these primary care physicians education and training to enhance their confidence and care of older adults in both social and medical care. Our training is interdisciplinary and all geriatricians should be able to do everything discussed above. The real issue is how little a geriatrician makes compared to the plastic surgeon, urologist, orthopeic surgeon. As long as reimbursement fails to reward non proceedure based geriatricians, there will be less incentive for doctors to enter geriatrics. If a provider makes more removing a mole than the social care coordination of a frail adult, there will be more gaps like discussed.

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