The promise of coordinated care between healthcare settings doesn't always work the way it should, writes Fred N. Pelzman, M.D., a New York-based internal medicine physician, in MedPage Today.
Take the case of an elderly patient who lives in a long-term care facility and the frustration of one of the medical interns who works in Pelzman's practice:
The intern called Pelzman concerned about his patient's declining health and the fact the medical staff at the nursing home were not following through with orders to manage her care and not returning his phone calls. Despite the intern's efforts to coordinate care for his elderly patient, her kidney disease has worsened, her diabetes is not being controlled and management of her anticoagulation has been virtually impossible, according to the article.
For this chronically-ill elderly patient, the promise of coordinated care has failed. "One of the foundations of the patient-centered medical home is that care must extend beyond the office visit," writes Pelzman. "Our whole point of caring for this patient, for all of our patients, is that we need to send them out into a world where their health continues to improve, where the medical orders we place, the prescriptions we write, the dosing we addressed, do not fall on deaf ears, but actually get put into practice, get applied to the patient to bring her to a better state of health."
Pelzman praises the passion of his medical intern and notes that--despite having left messages for the medical director at the long-term care facility--there has been no response. Moving her to another facility may be the only way to get this elderly patient the care she needs.
To learn more:
- read the article