“Care transitions” is a phrase that folks in the health care industries are becoming familiar with, and that the general public will hear more and more about as well as attempts at health care reform continue. Care transitions is not a complex concept. For a lot of us, frankly, including at Support For Home Health Care, it is a “Duh!”
Care transitions, conceptually, simply reflects that as a patient moves from home to hospital to rehab facility to home (or anywhere in between that care is provided, the care must be continuous, but dynamic. Needs and services required as the patient transitions from location to location, over time.
So, yes, conceptually there is nothing mysterious about the notion of care transitions. However, managing and implementing those transitions is tricky and far from seamless, in our current health care system. In fact, The Remington Report indicates researches blame inadequate management of care transitions for $25-$45 billion in 2011 wasteful spending.
A very significant part of the problem of managing care transitions is that Medicare increasingly points to the primary care physician (PCP) as the hub of the wheel for the patient, but communication to the PCP from various points out on the rim of the wheel is typically poor and the PCPs are buried in day-to-day care for their patients.
The wheel keeps spinning, for each patient, especially for seniors, many of them have multiple chronic medical conditions. Unless there is someone whose real job it is to connect the PCP to hospitalists and specialists and skilled nursing facilities and home health providers and non-clinical home care agencies and … the transitions are not going to be smooth and hospital readmissions are going to be much more frequent than any of us want.
At Support For Home Health Care, we believe that this is one of the roles of the Geriatric Care Manager (GCM). To address this in our own shop, our Client Services Manager is a gerontologist by academic training and our Director of Patient Care Services is a very senior RN. These folks are able to – and charged with the duty to communicate with the hospitals, rehab centers, nursing facilities and other folks out at the end of the spokes of the health care system – including family and professional non-clincal caregivers – and tie them together with the PCPs at the hub.
We believe this model will have to become increasingly prevalent as we move forward, if health care reform is to produce both increased quality of care and decreased costs.
What are your thoughts on this challenge?
Best wishes. Bert