Who is Coordinating Your Care? 5 Solutions and Tips to Beat the Odds

Posted on September 13, 2022

If you are over a certain age, or caring for someone who is, or someone with multiple medical conditions and diagnoses, there is a good possibility all aspects of your health care are not adequately coordinated. The average patient forgets Upward of 80% of what they hear.

If you are over a certain age, or caring for someone who is, or someone with multiple medical conditions and diagnoses, there is a good possibility all aspects of your health care are not adequately coordinated.

“Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” [i] Essentially making sure each doctor is reviewing the records detailing what your other physicians, therapists and other specialists are doing for you in terms of tests and procedures.

The goal of care coordination is to deliver high-quality, high-value care. Assuring each patient’s needs and preferences are known - and communicated at the right time to the right people with that information serving as guide to assuring the delivery of safe, appropriate and effective care.

This is accomplished through:

· Team work – everyone involved with the patient’s care; who is responsible for what; creating a proactive care plan; supporting the patient’s needs and self-management goals; monitoring and follow-up in response to changes in the patient’s needs.

· Care management - communicating and sharing knowledge; assistance with transitions of care; linking to community resources as needed.

· Medication management – communication among providers to assure all involved are aware when medications are added or discontinued.

· Health information technology – communication; sharing of knowledge; aligning resources with patient; population needs and billing.

· Patient-centered medical home – communication; assisting with transitions of care; aligning resources with patient needs.

The average patient forgets Upward of 80% of what they hear.

Additionally, most patients are unable to communicate their treatment and management instructions to their care partner(s).

Clearly, care coordination is not working as intended. Three out of four patients, age 65+, leave the hospital with an incorrect prescription or no understanding of the medication regimen to follow after discharge. About 20% of hospital patients are back again within 30 days, about one-third of those due to medication issues.[ii]

5 Care Partner Solutions and Tips to Beat the Odds:

1. Don’t Do It Alone

I am a strong champion of the need for each patient to have a care partner advocate (spouse, son, daughter, trusted friend or independent professional)It i by their side with every medical visit, ER visit and hospitalization. Advocates need to be present even if merely serving as the extra pair of eyes, ears and hand to support their loved-one’s care.

It is important to remember that every patient should understand: the diagnosis, type of treatment being recommended and why that particular treatment is the best for that patient?

For those not able to do so – an advocate should be present during all visits.

2. Take Good Notes

Remembering all the many doctor’s visits, nurses, therapists and other instructions can be a challenge. Making sure that everyone is literally on the same page with the same information - all caregivers, the patient and family can also be difficult. A reliable and practical, simple solution is to bring a good old-fashioned notebook and a supply of pens.

a. Jot questions to remember to ask (and the answers you get).

b. List loved ones’ goals, concerns and questions to share with doctors and nurses.

c. Keep a record of all medications prescribed, given and stopped.

The answers you get will come in handy during follow-up doctor appointments.

3. Hospital, ER and Physician Visit Records

Hospital records can take up to 30 days to get to patient’s doctors, yet patients are urged to have follow-up doctor appointments within about 10 days of discharge. You’d be surprised by how incomplete and inaccurate medical records can be!

a. Make sure to have a copy of the complete discharge plan.

b. Arrange to meet with a representative of the Medical Records department to sign a release of medical records Review them, looking for discrepancies or anything that seems not quite right.

c. Do not leave the ER or a physician’s (including specialist’s) office visit without instructions including, ordered tests, medication list, and follow up instructions.

4. Medications

Look up every medication given to your loved one in online drug directories – Drugs.com, for example.

a. Know side-effects and interactions to watch for.

b. If your loved one is over the age of 65, make sure you have a copy of the Beers list of medications, which is available online.

We metabolize medication differently as we age, and since our health care system is not flush with gerontologists, some doctors may not be aware of the medications on the Beers list that are “red flagged” for older adults. It’s good to read about this list before you ever need it – simply Google, The Beers List, or go to ISMP.org (Institute for Safe Medicine Practices) for more info and the complete list.

5. There are lots of different types of tests!

Blood and urine, MRI, x-ray, CAT scans, just to name the most common. In your notebook, keep track of …

• Test name

• Who ordered it?

• Why? To find out ask . . .?

• When will it occur?

• How will the results be used?

• When will the results will be ready?

• When will the patient will hear results? By whom?

Final thoughts and reminders

There should be no surprises. Patients and their designated care partner(s) need to be kept up to date and included in all decision making. Medical staff, case managers, etc. should know and understand pt’s goals with a goal of working toward attainment.

You’ve got this. Any questions or comments, don’t hesitate to reach out by email: [email protected] or schedule a 30-minute consultation by visiting: www.patientadvocatesofswfl.com or Appointments - Patient Advocates of SW Florida to discuss questions or concerns you may have.

[i]Department of Health and Human Services, Agency for Healthcare Research and Quality. Care Coordination | Agency for Healthcare Research and Quality (ahrq.gov). August 2018.
[ii]Community Education - The Care Partner Project. A Safe & Sound Hospital Stay: How to Get the Care You Want for the People You Love.