Importance of Coordination of Care for Seniors

Many of your senior patients have one or more chronic conditions and are cared for by more than one physician, which makes your job of managing drug-disease and drug-drug interactions more difficult. Coordination of care among caregivers becomes essential as the complexities of your senior patients’ health problems increase.

When coordination of care breaks down, it can lead to:

• Missed or delayed diagnoses
• Missed or delayed treatment
• Repeated or unnecessary testing
• Adverse drug reactions

Nearly half of all Americans live with a chronic illness, and almost half of them have multiple chronic conditions.

Communication & Collaboration
Communication and collaboration with your patients and with their other caregivers are key to effective coordination of care. Ask your patients what is and what isn’t working for them in the current course of treatment. Encourage your patients to ask questions. Asking patients to repeat back the important information you have discussed is one way to clear up misunderstandings.

A Commonwealth Fund study showed patients encountering conflicting information from different health care professionals. The study also showed that many physicians had not discussed and reviewed all of a patient’s medications in the past two years.

How Can You Help Improve Coordination of Care?
Some ways you can improve coordination of care for your senior patients include:

• Keep an updated list of all of your patients’ current medications and the other health care professionals they see. Keep other members of your patients’ health care team informed of medications you prescribe, tests you run, and diagnoses you make.

• Consider a secure data-sharing system for your office that would facilitate sharing information with other members of your patients’ health care teams.

• Implement reminder systems in your office that will notify staff when patients need to come in for tests or screenings and that will ensure follow-up with patients when results come in.

• Consider adding a nurse care manager or a care coordinator to your staff to help manage your patients who have multiple chronic conditions.

• Consider ways to supplement face-to-face office visits, like e-mail, phone conversations, interactive Web applications, or letters or postcards. Patient-centered care is another way that physicians can improve outcomes for patients with chronic conditions. Patient-centered care is, more and more, recognized as a key ingredient of health care quality.

According to the findings of a recent study, adults who had chronic conditions were prescribed the recommended care just 56% of the time.

Proponents of the patient-centered model, in which patients are encouraged to be proactive, be informed, and ask questions, say it leads to patients who are more satisfied and who adhere better to treatments. Some elements of patient-centered care are:

• Giving patients information and educational materials that allow them to set their own goals via shared decision-making with their health care providers

• Providing patients with same-day appointments when appropriate, quick replies to calls, and referrals to resources in the community

• Offering emotional support to patients to help with fear and anxiety about a diagnosis or prognosis

Provided as an educational resource by Merck