GeriTech

In Search of Technology that Improves Geriatric Care

care coordination

Care Coordination Around Hospitalization, Part 2

You may be wondering what happened with Ken, whom I wrote about in my last post.

Well, he stayed in the hospital for 4 days. At the end of his first day, a palliative care consultant called me and left me a voicemail with recommendations related to pain and constipation. He left me a cell phone number. He didn’t answer when I called him back, so I left a brief message and thanked him for the update.

But no hospitalist ever called me and no updates were faxed to me. On the fourth day (a Monday), I called the floor and again asked to speak to his doctor. His nurse came to the phone, explained to me the discharge plans, and then asked if there was anything else I needed.

Well, yes. I need to know what happened to him medically, not just what facility they were planning to discharge him to. Why did they keep him for so many days? Ken himself had left me messages saying the doctors were doing a lot of tests but not telling him the results. (Patient-centered hospital care, where art thou?)

The nurse was unable to answer these questions. I said that I wanted results of the tests faxed to me, and that I’d also like to talk to his doctor.

Several hours later, a doctor finally called me. He sounded young and harried. “So, what do you need to know?” he asked me. [Read more…] about Care Coordination Around Hospitalization, Part 2

Care coordination when patients go to ED or hospital

My patient, who lives in assisted-living, went to the Emergency Dept and then was hospitalized last night. (We’ll call him Ken.)

So once again I get to see what works well and what works less well, when it comes to care coordination. As usual, I’m not impressed, although things could be worse.

In part, they are not so bad because I’m the one who urged Ken to go the ER. Whereas my patients are often sent to ER without anyone even calling me first, in this case, I knew he was going, and was even able to take action to smooth the process.

An added bonus: Ken has a  long-time care manager who I connect with regularly, and she arranged for the transportation there and stayed with him for the first few hours.

Furthermore, to help Ken get the right care from the ER and to facilitate coordination of care, yesterday I wrote a note for the ER doctors. Ken’s care manager brought this with them to the ER, along with a medication list from the facility.

In my note, I summarized:

  • The most important aspects of Ken’s past medical history
  • Recent changes to his health — including recent lab and radiology results — and why we were sending him to the ER
  • Information on Ken’s background, including the fact that he’d been living at the facility for a few years, that he’d had the same care manager for years, and that he’d been homebound due to a psychiatric condition, which caused him to refuse to leave the facility to see his assigned PCP
  • Information regarding Ken’s preferences for medical care, including the fact that he’d consistently refused medical care meant to extend his life, and had repeatedly emphasized a desire to have pain and comfort addressed
  • Information regarding Ken’s usual mental capacities and decision-making capabilities
  • My contact information (phone and fax)

In short, Ken arrived at the ER better equipped than most to facilitate care coordination.

Now here is what has happened so far:

  • I have heard nothing from the ED, by phone or fax. It was Ken’s care manager who sent me an update last night, and then this morning informing me he’d been admitted.
  • I called the hospital this morning and left a message saying I wanted the nurse or doctor to call me. That was over 4 hours ago and nothing yet.

I’m not surprised by this, but it’s still disappointing. If I send a patient to the ER, with a note that includes my fax number, is it crazy to expect the clinicians to fax me something about what they found and did??

How I did get an update on my patient’s ER course and hospitalization

[Read more…] about Care coordination when patients go to ED or hospital

Two Must-reads from JAMA’s Critical Issues in US Healthcare

This week’s JAMA issue is titled “Critical Issues in US Healthcare” and wow, it is a goldmine of good reading for those interested in the state of healthcare today.

So far I’ve read two particularly outstanding articles that I want to recommend. (If you don’t have personal or institutional access to JAMA, apparently you can access JAMA “free for a limited time” by signing up for their JAMA Network Reader.) They are “Reliable and Sustainable Comprehensive Care for Frail Elderly People,” by geriatrician Joanne Lynn, and “The Anatomy of Healthcare in the United States,” by Dr. Hamilton Moses et al.

“Reliable and Sustainable Comprehensive Care for Frail Elderly People.” 

In this article, Dr. Lynn begins by describing some sobering realities:

“As the incidence of sudden and premature deaths has declined in the United States, the last part of most individuals’ lives has come to be marked by progressive chronic illnesses and diminishing physical reserves that engender self-care disabilities and frailty. Those who live past age 65 years now average 3 years of self-care disability at the end of life, needing long-term services and supports (LTSS). For those living past 85 years old, nearly half will have serious cognitive decline.”

The problem, as Dr. Lynn points out, is that our fragmented, specialty-driven, acute-care-focused healthcare system is poorly set up to help people during this phase of life, during which frail elders need comprehensive coordinated care that helps them maintain function and quality of life. Furthermore, much of what people need in the last phase of life is not covered by Medicare, e.g. supportive services that help older adults with their living needs.

Instead, Dr. Lynn notes that these needs have been treated as something that individuals should save for, and that families should step up to address. But this is a huge burden for people and families to shoulder, and will be even harder to maintain as the population skews older over the next few decades. (The ratio of working people to dependent and disabled older adults, which was 5:1 in 2011, is expected to  decline to 3:1 by 2029.)

Fortunately, Dr. Lynn has some solutions for us to collectively consider. She begins by urging society to recognize that “frail elderly people have different priorities and needs than they had earlier in life, and their care system must reflect those priorities.” She notes that discussions about living with frailty are largely absent from popular media and public conversation, and calls for “vigorous discussion about how people live well with frailty and how best to die.”

She then goes on to advocate for a number of sensible changes, including individualized medical planning, multidisciplinary assessment and management, new metrics of healthcare quality for this population, and redesign of healthcare delivery models.

Most importantly, she advocates for healthcare services and long-term services and supports to be considered equally important, and ideally integrated:

“A balanced system would give integrated multidisciplinary teams the tools and authority to match services with each frail person’s priority needs. Food, housing, transportation, and direct personal services are often more important than diabetes management or chemotherapy. Elderly people and their families often choose comfort, function, and familiar environments and relationships over small chances for cure or longer survival. Medicare’s open-ended entitlement to medical interventions contrasts with the limited and often inadequate safety-net programs to support personal needs, and this mismatch complicates development of a coherent and efficient service delivery system.”

The issue, of course, would be how to fund and finance such a program. Dr. Lynn doesn’t go into great detail in this article (her prior work has addressed this in the past), although she mentions the possibility of a “MediCaring” ACO taking this on. She also notes that we currently have some models, such as PACE (Program of All-Inclusive Care for the Elderly) and the VA’s Home-Based Primary Care, that we might learn from.

Obviously, this article doesn’t have all the answers for those of us who want better care for an aging America. Still, I like the way Dr. Lynn frames the needs that people have during this last fragile stage of life, and her description of how our current system is really a terrible match. I also agree that we need to have more conversations about those last frail years that many people will undergo.

Will we soon be moving towards a system of integrated healthcare and long-term care for frailer elders? Only if the public demands it, I think…which hopefully they will.

“The Anatomy of Healthcare in the United States“

This is a much longer article, combining very interesting summaries of healthcare data with thoughtful reporting on core trends in healthcare, and insightful commentary on some of the thorny tensions that really might rip the healthcare system apart if we don’t find ways to resolve them.

The juiciest data items are summarized in the abstract:

“The findings from this analysis contradict several common assumptions. Since 2000, (1) price (especially of hospital charges [+4.2%/y], professional services [3.6%/y], drugs and devices [+4.0%/y], and administrative costs [+5.6%/y]), not demand for services or aging of the population, produced 91% of cost increases; (2) personal out-of-pocket spending on insurance premiums and co-payments have declined from 23% to 11%; and (3) chronic illnesses account for 84% of costs overall among the entire population, not only of the elderly.”

In short, we healthcare providers have been charging more and more, and administrative costs have been going up. Out-of-pocket spending stinks for patients but so far apparently hasn’t been rocketing up in the same way.

And surprise surprise, chronic illnesses are driving most of the cost. (Cue the crowd that loves to promote prevention as the main way we should manage the chronic disease.) To my surprise, this analysis found that 67% of the costs of chronic illness are in people younger than 65, but still, I expect that management of chronic disease will be very important to Medicare over the next 10-20 years.

My next favorite part is also nicely summarized in the abstract:

“Three factors have produced the most change: (1) consolidation, with fewer general hospitals and more single-specialty hospitals and physician groups, producing financial concentration in health systems, insurers, pharmacies, and benefit managers; (2) information technology, in which investment has occurred but value is elusive; and (3) the patient as consumer, whereby influence is sought outside traditional channels, using social media, informal networks, new public sources of information, and self-management software.” [Emphasis mine.]

And then there’s the highlighting of problematic tensions currently affecting healthcare. I will again quote the abstract:

“These forces create tension among patient aims for choice, personal care, and attention; physician aims for professionalism and autonomy; and public and private payer aims for aggregate economic value across large populations. Measurements of cost and outcome (applied to groups) are supplanting individuals’ preferences. Clinicians increasingly are expected to substitute social and economic goals for the needs of a single patient. These contradictory forces are difficult to reconcile, creating risk of growing instability and political tensions. A national conversation, guided by the best data and information, aimed at explicit understanding of choices, tradeoffs, and expectations, using broader definitions of health and value, is needed.”

Wow. It really is not often that I come across an article that clearly calls out several big problems and how they are intertwined. (Most articles just hack at one specific part of the problem…kind of the way specialists hack at one specific organ while no one summarizes the key overall problems for the patient.)

The article itself is long and a bit wonky, but overall much more readable than many health policy articles. There’s a very good section summarizing the changing role of patients and consumers in healthcare, and also an interesting section referring to direct-pay and “concierge” medicine.

Regarding team-based care and reallocating healthcare work among professionals, the authors make the following observation:

“…given the shift in orientation to measurement of success with populations rather than individuals, there is a struggle between efforts to manage professionals systematically and efficiently and traditional structures that reflect preference for autonomy, hierarchy, and historically based professional values. These factors, along with increasing patient assertiveness, create the primary management challenge of this era.” [Emphasis mine.]

So true, and what we are going to do about it I really don’t know. In general the strength of this article is in describing the situation and some very important conflicting forces that are keeping healthcare mired in dysfunction; solutions are obviously another (much more difficult) story.

I especially enjoyed the description of an “iron triangle” of conflicting forces:

  • Patient expectations for individual care and personal attention; 
  • Physician autonomy; 
  • Value as defined by policy makers using health status of large groups and aggregate measures of cost.
This is really one of those articles that I will have to reread and highlight more extensively. 
Whew. We have our work cut out for us during these next 10-20 years in an evolving healthcare system. 

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

Wanted: A managed personal health record for assisted living

 [The following clinician guest post is by Dr. Alan Pitt, who is helping to plan a senior living community under development. We met recently at Health 2.0, and he was nice enough to write a post about the tech tool he is currently looking for: a managed personal health record. (This post is cross-posted to his blog too.) Thanks Alan!]

“I’m not as scared of dying as I am of growing old.” – Ben Harper, Glory and Consequence

Whether we admit it or not, most of us are afraid of growing old. There is a sense of loss, of youth and vigor, coupled with the burden of managing your health in relative isolation. Although Americans would like to think that we are each responsible for our own care, most of us as individuals would far prefer for someone to be there, helping us through our time of need. Years ago I was advising one of the Presidential hopefuls regarding a healthcare platform. I suggested that the position should be that individuals be responsible for their own health, but as a country we would partner to provide the tools for the individual to succeed. Now, almost a decade later, we are not much closer to this goal.

Personal Health Records (PHRs) were thought to be the answer. These records differ from more traditional EMR in that they are owned by the patient and aggregate information from multiple sources to give a complete picture of the patient. For example, they might include clinic visits from multiple providers, hospitalizations and updates on an exercise program. Literally billions were spent on PHRs by the likes of Microsoft (HealthVault) and Google. Both efforts were failures with thousands (in the single digits) rather than millions of enrollees. As noted by David Shaywitz, healthcare is a negative good, something viewed more with resentment than in any way positive. And that extends to things that keep us healthy. To interact with your health means you are imperfect, you are mortal.

Rather than a PHR, I would like to propose a different tool, a managed PHR (mPHR). This would be owned by the patient, but managed by a surrogate, such as a family caregiver or even a care coordinator (CC). This person would be responsible to keep the person on track, taking their medications, keeping their appointments, explaining their illness (or at least researching their problem). This may seem far fetched, but I believe CC will be a new job in 3-5 years. And when this army spreads across the land, they’ll look for a tool to do their work. And it won’t be an EMR. It will be a mPHR.

What would the perfect mPHR do? 

Here is a list I’ve compiled:

  • Collect and organize data from disparate hospitals and clinics 
  • Store and view previous radiology exams 
  • Facilitate med reconciliation and education
  • Send reminders
  • Manage exercise programs
  • Allow differing levels of permissions and access…for the patient, the advocate and family
  • Message those defined in the persons ecosystem if the PHR identifies a down trend.
  • Report on utilization and changes in utilization
  • Collect biometrics such as weight and blood pressure, and also track problems such as depression and pain indices with reporting and messaging
  • Link/suggest support groups based on the problem list 
  • Leverage secure texting and email for messaging
  • Be platform agnostic & cloud based

The critical thing here is actually not the functional requirements…these have already been fairly well defined…it is the ability to easily work with surrogates and family while maintaining some level of choice and control by the patient.

This is not an idle ask. I am now working with a developer building senior communities with integrated care and care coordination. I can buy an EMR, but not an effective PHR for these communities. With any luck at all, we will be managing thousands of lives in these communities in the next few years.

To all you bright entrepreneurs out there, help me out. Build the perfect mPHR. If I am right, and there is a lot of evidence I am, you’ll transform how we care for one another, and make a lot of money doing it. I won’t be your only customer.

Alan Pitt, MD, is a Professor of Neuroradiology at the Barrow Neurological Institute in Phoenix, AZ, and has been a speaker at Health 2.0. His skills and talents include cloud-based informatics, innovations in telehealth, and finding financially sustainable ways to improve healthcare. You can reach him at alanpitt [AT] me [DOT] com.