Over the course of my career, I have had numerous older or aging patients. Some have aged gracefully … maintaining an active lifestyle well into their eighties. They run, they play tennis, they have an active love life and they are involved in many outside interests. At the other end of the spectrum are the patients who were in my office almost weekly, beginning when they just reached their fifties. They had heart problems, mobility issues and other health concerns that severely restricted their daily lives.
We know that aging has consequences … bones and joints start to wear out, there is a loss of muscle tissue, routine illnesses can be life-threatening and problems appear overnight from the years of bad habits like alcohol consumption and tobacco use.
So, is it fair to say that getting older in and of itself a chronic disease? If it is, how is it best managed?
Let’s work with a specific patient, Mrs. Grant, who has these issues: chronic pain and numbness, congestive heart failure, depression and obesity. What are the steps to ensure this patient’s care is coordinated between her Primary Care Physician (PCP), her cardiologist her neurologist and, possibly, a pain management doctor?
Beginning with the office visit, Mrs. Grant should bring a family member or caretaker. The presence of another person will help ensure a better understanding of the doctor’s instructions and other information.
The physician must also be knowledgeable of patient’s medications. Multiple prescriptions for Mrs. Grant create a risk for adverse drug events (ADEs). Also, if the PCP adjusts medication(s) or discontinues them, the pharmacist, cardiologist, neurologist and/or pain management doctor should be alerted. It’s a good plan for the patient to always bring all their medications when making an office visit. Multiple prescribers pose a risk for these patients.
It is important for the patient to establish a good rapport with the physician’s office staff. The more the staff knows about each patient, the better prepared they are to get the patient an appointment as soon as necessary.
Electronic Health Records (EHRs) are crucial to care coordination. They save time and help prevent mistakes. If Mrs. Grant has seen a consultant, been admitted to a hospital or ER or received an imaging or diagnostic procedure, all of this data will be placed in the EHR and the PCP will have it at his/her fingertips. The challenge is that at this time not all providers are part of some type of health information exchange. There is still work that needs to be done by providers as well as states and the federal government for full connectivity to become a reality.
Potential problems for Mrs. Grant can be minimized with a care coordination approach and electronic communication with consultants, hospitals, ERs, home health and palliative providers. This integrated approach, including technological advancements, can ultimately increase the patient’s quality of care and quality of life. Sounds like a patient-centered medical home doesn’t it?
At the point of discharge or by a care coordinator, the communication between Mrs. Grant, her physician and her family advocate is essential to reduce the likelihood of a readmission to the hospital. For example, what should she do if she falls when she goes home or if she has a bad reaction to her new medicine?
On-going communication with the patient is essential to prevent future complications and an understanding of the physician’s treatment plan.
Old age doesn’t have to be chronic chaos, fully coordinated care can be part of the cure and management.