Medical care for older adults can be complicated. People often have many different health care professionals at different locations. Travel and transportation issues become more difficult as people age. The medications that are covered by the Medicare prescription drug plan vary between insurance companies and change frequently. Assistance by a team of health care professionals under the leadership of a primary care physician or a doctor who specializes in the care of older adults (geriatrician) is the best way to deal with these complexities.
Continuity of care is an ideal in which health care is provided for a person in a coordinated manner and without disruption despite all the complexities of the health care system and the involvement of different professionals in different care settings. Also, all people involved in a person’s health care, including the person receiving care, communicate and work with each other to coordinate health care and to set goals for health care.
However, continuity of care is not always easy to accomplish, especially in the United States, where the health care system is complicated and fragmented. When continuity of care is missing, people may not adequately understand their health care problems and may not know which health care professional to talk to when they have problems or questions.
Challenges to Continuity of care
Continuity of care is a particular concern for older adults. Older adults are particularly likely to have several doctors and other health care professionals (each specializing in one organ system or problem) and thus to move from one care setting to another (called transition of care). They may receive care in several private medical offices, in a hospital, in a rehabilitation facility, and/or in a long-term facility.
Many doctors and other health care professionals
Receiving care from several doctors and other health care professionals may disrupt the continuity of a person's health care. For example, one health care professional may not have up-to-date, accurate information about the care provided or recommended by other clinicians. That health care professional may not know the names of the other clinicians involved, may not think to contact them, or may find that contacting them is logistically difficult. Information about care may be miscommunicated or misunderstood, particularly when older adults have disorders affecting speech, vision, or mental function (cognition) that make it more difficult for them to communicate effectively. People may mention an important detail to one health care professional but not mention it to the others.
To ensure that care is continuous (and optimal), all clinicians involved must have complete, up-to-date, and accurate information about what other health care professionals have done, particularly about tests done and medications prescribed. When this information is missing or miscommunicated, the following can result:
Diagnostic tests may be needlessly repeated.
Inappropriate medications or other treatments may be prescribed.
Preventive measures may not be taken because each health care professional assumes someone else has provided them.
Different clinicians may have different opinions about a person's health care. For example, doctors in a hospital may disagree with a person's primary care physician about whether surgery is required or about whether the person should go to a nursing home after being discharged. The person and family members may be overwhelmed and confused by differences of opinion among the various clinicians.
People taking many prescription medications, as is common with older adults, may fill their prescriptions at different pharmacies (for example, the one nearest each specialist's office). When different pharmacies are involved, each pharmacist may not know all the medications people are taking and thus will not know when a newly prescribed medication might interact negatively with a current one.
Many settings
Moving from one care setting to another (transition of care), such as going from a hospital to a skilled nursing facility, increases the chance that errors in care may occur. New medications may be prescribed in the hospital, and they may duplicate or interact negatively with the person’s other medications. Sometimes medications prescribed previously that are still needed may be unintentionally omitted. Even when changes in people's medications are appropriate, the changes may not be communicated to all involved health care professionals, such as the primary care physician.
To prevent such problems, current regulations in the United States require health care organizations to do medication reconciliation whenever the care setting is changed and whenever new medications are ordered or existing orders are rewritten. Medication reconciliation involves comparing people's medication orders to all the medications they were previously taking and thus making sure no medications are duplicated or omitted. When changing care settings, older adults or their caregiver should ask health care professionals whether medication reconciliation was done.
If people are not in a health care facility, they and/or their caregivers should do their own medication reconciliation. People should keep a list of their current medications as well as a list of medications they used to take (and why they were stopped). Then, after people see a new clinician or enter or leave a hospital or other care facility, they should check whether any newly prescribed medications are on these lists. If people see any of the following, they should speak to a health care professional right away:
A duplicate prescription for a medication that they are already taking
A prescription for a medication that they previously needed to stop taking
A missing medication—one that they were taking but that is not on the facility's list of their current medications
Making an appointment with the primary care physician soon after discharge from the hospital or other care facility (such as a rehabilitation center or skilled nursing facility) is always a good idea. People should always bring their current list of medications as well as the actual bottles they are in. The clinician can then review all of the medications and instructions recommended at the time of discharge.
Many rules
The health care system has many rules that affect continuity of care. The rules may be made by the government, insurance companies, or professional organizations for health care professionals. For example, some insurance companies limit which hospital people can go to. The person’s primary care physician, if not on staff at that hospital, may be unable to provide care there. Also, many primary care physicians no longer provide care in hospitals or rehabilitation centers. As a result, a person in such settings may be cared for by new clinicians who are not familiar with the person's medical history. It is important for the person or the person's caregiver to make sure that all pertinent information is provided to the new clinician.
Lack of access to care
Continuity of care may be disrupted when people do not have access to health care. For example, older adults may miss a follow-up appointment because they do not have transportation. They may not see a health care professional because they do not have insurance and cannot afford to pay for health care themselves.
Other problems
People may forget or be unaware that they have an appointment with a health care professional.
Not all health care professionals participate in all Medicare Managed Care plans. Before seeing a new clinician, people with Medicare Managed Care plans should check whether that health care professional participates in their plan so that they do not face unexpected costs.
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.
Health Care System
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
Interdisciplinary care is coordinated care provided by many types of health care professionals, including doctors, nurses, pharmacists, dietitians, physical therapists, occupational therapists, and social workers. These health care professionals make a conscious, organized effort to communicate, cooperate, and come to agreement with each other about a person's care. Interdisciplinary care aims to ensure that people move safely and easily from one care setting to another and from one health care professional to another. It also aims to ensure that the most qualified health care professional provides care for each problem and that care is not duplicated. Interdisciplinary care is not available everywhere.
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 professionals, and those who have side effects from medications.
The various health care professionals who care for a particular person form the person's interdisciplinary team. One clinician, who may be the person's primary care physician or a social worker or care manager, coordinates care.
Sometimes the health care professionals 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 professionals 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 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 professionals on the team.
Geriatric care managers
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.
Electronic medical (health) records (EMRs)
EMRs contain health information about a person in a digital format. The purpose of an EMR is to enable all health care professionals caring for a person to see accurate, up-to-date, legible, and complete information about the person at any time.
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 clinicians caring for a person to communicate with each other more easily and more quickly
Reducing mistakes and omissions made because clinicians 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. Clinicians and hospitals often cannot read records created by clinicians and hospitals that use a different system. Furthermore, the information in EMRs is only as accurate as the data that are entered by previous clinicians, and data entry is often very time-consuming. When possible, people should verify the information contained in their EMR.
People Receiving Care
To help improve the continuity of their care, older adults 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 (see also Making the Most of a Health Care Visit). Asking questions about a disorder, treatment, or other aspects of care is important. When older adults have special health care needs or questions, they or their family members should tell their health care professionals. For example, older adults often need help determining which medications are covered by their Medicare prescription drug plan. They also may need help learning how to prevent disorders.
People or their family members who are active participants in the person's health care can be proactive. For example, older adults, or their caregivers,can establish an ongoing relationship with at least one health care professional, usually the primary care physician, to minimize the problems created by having several health care professionals. Older adults can communicate with their primary care physician about recent 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 professional to call and talk with another to make sure that information is communicated clearly and that treatment is appropriate.
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 (see also Handling Medical Records). They can often obtain a copy from their primary care physician. 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 professionals. 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 health care professional 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 (see sidebar What Should Be in a Personal Medical Record). 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 professional, 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 adults 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.
