A path to care coordination for seniors

There's an all too common scenario playing out in hospitals across America: elderly patients are being readmitted to the hospital, over and over, for health complications that could have been prevented through better care coordination.

Take John Doe as an example. John had bypass surgery six months ago and is taking medications for his heart condition and his ongoing type 2 diabetes. For the past three months, he's had bimonthly physical therapy (PT) sessions as part of his recommended care plan. His electronic health record (EHR) shows all of this. What's missing is the fact that he hasn't filled his diabetes prescription in a month nor attended his last two PT sessions. As a result, he has become less active and his blood sugar is out of control. He gets up from his chair, becomes dizzy, and falls, leading to an emergency room (ER) visit. If the information about his inactivity, missed PT visits and diabetes medication doses had been captured and integrated into his EHR, an earlier, home-based intervention might have saved him a trip to the hospital.

Roughly three out of four seniors experience a similar lack of care coordination. According to a survey by the John A. Hartford Foundation, just 27 percent of seniors are receiving the kind of coordinated care services seen in a patient-centered medical home. With 10,000 people turning 65 every day and 75 percent of seniors living with multiple chronic conditions, the need for coordinated care across multiple specialists and facilities has become vast and urgent.

Health systems can consider three digitally driven solutions to address this problem: designing senior-friendly health trackers, analyzing available data to determine gaps in care, and working with health information technology (IT) vendors to integrate data and deliver better patient experiences.

Making mhealth work for seniors. The wearables market is booming for all age groups except seniors and resistance to technology doesn't appear to be the main culprit given the high percentage of seniors who own a smartphone or computer. So why isn't your elderly patient using the smart blood glucose meter you prescribed to manage his or her diabetes and follow your recommended care plan?

Look at any sleekly designed, featherweight device and a plausible answer emerges – how easy would it be for someone with limited vision to see what's displayed on a small digital interface? Are the buttons big and deep enough to be pressed by someone with arthritis? Considering these design changes for wearables and features like voice recognition and recording for patient engagement apps can help seniors adopt mhealth tools that suit their physical needs and integrate more easily into their lives. Moreover, as the one in six consumers currently using a wearable knows, having an up-to-the-minute view of one's health is empowering. For seniors, this knowledge can translate into more active participation in their care plans.

Analyze EHR data. Most medical records include data on when a patient last came in for an annual test or had basic preventive services. This makes it possible to run a simple analysis revealing who needs to come in for a booster shot or is overdue for a mammogram or colonoscopy. With this information, clinicians can mail out reminders or call patients at home to prompt them to make an appointment. These senior-friendly methods of notification recall the end user who may not wish to check email or log into a patient portal to find out why their doctor is contacting them.

Analyzing EHR data in this manner has worked well for Humana's Medicare population, potentially saving at least one life. The insurer's claims data is scanned every night for a number of warning signs, including disease risk factors and individuals who are of a certain age. Recently, one analysis uncovered that an at-risk individual had yet to come in for a cancer screening or even his regular physical. An appointment was quickly scheduled, during which an early-stage cancer was detected. He is now healthy and cancer-free, thanks to the analytics built into Humana's claims workflow, which triggered healthcare plan managers to contact him. This real example provides a view into the future of healthcare where medicine is practiced proactively, a life is saved and a care team and health plan have one less costly care regimen to coordinate.

Collaborate with a health IT vendor on the road to interoperability. While most health systems are working to integrate their datasets, it can be difficult to know where to begin with multiple inputs originating from disparate facilities, ranging from out-patient clinics to pharmacies and even seniors' homes. Going to a health IT vendor with a specific need or idea for achieving a certain outcome, and collaborating on a solution, is another way to attain the interoperability necessary for enabling care

One data integration that has worked well at Humana is bringing together benefits and prescription information so pharmacy benefits are maximized at the point of prescription and at the pharmacy. This pharmacy benefit management program helps clinicians, pharmacists and benefits managers communicate and work together to create a care plan that seniors can adhere to. From a patient's perspective, the benefits are significant. They don't have to go to the pharmacy multiple times because the authorization process is more streamlined, avoiding unnecessary delays. They aren't overmedicated because duplicated or conflicting prescriptions are flagged. And unpleasant financial surprises become uncommon as the medication regimen they're picking up from a single location has been fully analyzed according to their benefit plan as well as their clinical needs.

With this particular data integration in place, what health systems can then look to is a way to capture patient information from the pharmacy, as many are now doubling as clinics. This out-patient setting provides another opportunity for seniors to communicate their healthcare needs and for care professionals to record them to create a sharper picture of an individual's health.

These three ideas are all available now. We have pieces in place that will help with care coordination for seniors, but we need to engage the end users – seniors, their families or caretakers, and physicians or care teams. By designing better digital health experiences for seniors, analyzing the data health systems we have at hand, and making strides toward data integration and interoperability, we can achieve the coordinated care needed to help seniors stay healthy and active at home and — most importantly — out of the hospital.

By Dr. Thomas J. Van Gilder, Chief Medical Officer and Vice President of Informatics and Analytics, Transcend Insights

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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