older people’s health issues
Continuity of Care
Strategies to Improve Continuity of care
Improving continuity of care requires efforts by the health care system, by the people receiving care, and by family members. Managed care organizations and some government health care plans coordinate all health care and thus contribute to continuity of care. Also, the health care system has developed several strategies to improve continuity of care. Examples are Interdisciplinary care Geriatric care managers Electronic medical records Interdisciplinary care is coordinated care provided by many types of practitioners, including Doctors , Interdisciplinary care is particularly important when treatment is complex or when it involves movement from one care setting to another. People who are most likely to benefit include those who are very frail, those who have many disorders, those who need to see several different types of health care practitioners, and those who have side effects from medications. The practitioners who care for a particular person are called the interdisciplinary team. One practitioner, who may be the person's primary care practitioner or a social worker or care manager, coordinates care. Sometimes the health care practitioners on an interdisciplinary team do not work together on a regular basis (an ad hoc team). They come together to meet a particular person’s needs. In other situations, there is an established team with the same members who usually work together and who care for many people. Some nursing homes, hospitals, and hospice organizations have established teams. Team members discuss plans for treatment and inform each other about changes in the person’s health, changes in treatment, and results of examinations and tests. They make sure that the person’s records are up-to-date and that the records accompany the person through the health care system. Such efforts help make changes in care settings or in health care practitioners smoother and less traumatic. Also, tests are less likely to be repeated unnecessarily, and mistakes or omissions in treatment are less likely. The interdisciplinary team also includes the older person being cared for and family members or other caregivers. For effective interdisciplinary care, these people must actively participate in care and must communicate with the health care practitioners on the team. Geriatric care managers are specialists who make sure that an older person receives all the help and care needed. Most geriatric care managers are social workers or nurses. They may be members of an interdisciplinary team. Geriatric care managers can make arrangements for the services needed and supervise these arrangements. For example, care managers may arrange for a home nurse to visit or for an aide to help with housecleaning and preparation of meals. They may locate a pharmacy that delivers medications or arrange for transportation to and from the doctor's office. Geriatric care managers may be members of the team in a health care organization such as a clinic. Alternatively, patients and families may be able to hire them at an hourly rate, which is not reimbursed by Medicare. EMRs contain health information about a person in a digital format. Their purpose is to enable all health care practitioners caring for a person to see accurate, up-to-date, legible, and complete information about the person whenever they need to. EMRs typically contain demographic and personal information (such as age and weight), the medical history (including vital signs, medications being taken, allergies, and immunization status), test results (of laboratory and imaging tests), and billing information. EMRs can improve care by Enabling practitioners caring for a person to communicate with each other more easily and more quickly Reducing mistakes and omissions made because practitioners lacked needed information Reducing the number of duplicated tests Reducing delays in treatment Enabling people to have access to their medical records and participate more fully in their own health care However, there are many different EMR systems. Practitioners and hospitals often cannot read records created by practitioners and hospitals that use a different system. Furthermore, the information in EMRs is only as accurate as the data that are entered by previous practitioners, and data entry is often very time-consuming. When possible, people should verify the information contained in their EMR. To help improve the continuity of their care, older people and their caregivers (whether family members, people outside the family, or both) can take an active part in their care. For example, they can learn more about what can interfere with continuity, how the health care system works, and what resources (such as care managers or social workers) are available to improve continuity of care. Being familiar with their disorders and the details of their health insurance plan can also help. Active participation begins with communication—giving and getting information. When older people have special health care needs or questions, they or their family members should tell their health care practitioners. For example, older people often need help determining which medications are covered by their Medicare prescription drug plan. People who are receiving care or their family members need to become proactive in care. For example, older people, or their caregivers, need to establish an ongoing relationship with at least one health care practitioner, usually the primary care practitioner, to minimize the problems created by having several health care practitioners. Older people should make sure the primary care practitioner is aware of changes in their condition and their medications, especially when a specialist has made a new diagnosis or changed a treatment regimen. They may need to ask one health care practitioner to call and talk with another to make sure that information is communicated clearly and that treatment is appropriate. Active participation means asking questions about a disorder, treatment, or other aspects of care. It also includes learning how to prevent disorders and taking the appropriate steps to do so. For people who have a disorder, active participation often involves following a healthy lifestyle. For example, people with high blood pressure can follow a heart-healthy diet and exercise regularly. People can also monitor their condition at home. For example, people with high blood pressure can check their blood pressure, and people with diabetes can measure the level of sugar in their blood. Keeping a copy of their medical record can help people participate in their health care. They can often obtain a copy from their primary care practitioner. A copy of the medical record is useful as a reference for information about current disorders, medications being taken, treatments and tests done, and payments made. This information can also help people explain a problem to other health care practitioners. File boxes, binders, computer software, and internet programs have been designed for this purpose. Additionally, many doctors' offices provide secure, online portals that people can access to view their laboratory results, prescription information, and summaries of office visits. When more than one practitioner is involved, people can keep their own records of their care, including the type and date of examinations and procedures and a list of their diagnoses. At a minimum, people should keep a record of all medications (prescription and nonprescription) they are currently taking, plus the doses and the reason they are taking the medication. They should bring this record with them each time they visit a doctor. When people go to a hospital or to a new health care practitioner, they should check with someone at the new location to make sure that their medical record has been received. Buying all medications (prescription and nonprescription) at one pharmacy or through one mail order service and getting to know a pharmacist there are also important. Older people can ask their pharmacist questions about the medications they are taking. They can also ask for containers that are easy to open and labels that are easy to read. 