An estimated 133 million Americans – 45 percent of the population – suffer from chronic illnesses. For these people, navigating the American health care system can be especially difficult. It is not unusual for patients with chronic illnesses to visit multiple specialists, in addition to their primary care physicians. With so many practitioners involved in the care of a single patient, communication is especially essential so that there are no gaps or overlaps in treatment.
Wrap-around care serves as a resource for chronically ill patients, their doctors, and their caregivers. When doctors have a full support team working together to oversee and manage treatment, they can focus on better managing their patient’s treatment across multiple points of care. Similarly, patients can benefit from this support team: their level of care increases, which can help prevent unnecessary hospitalizations.
The Patient Experience Without Synchronized Care
As an example, an older man seeks treatment for a fall he experienced the day before. In assessing his condition, the nurse can tell that this man exhibits signs of dementia. The nurse also knows this man must visit an ER, as the medical center is not equipped with a CT scan. However, the man’s dementia prevents him from driving, and he is not sick enough to warrant ambulance transportation. Eventually, the man finds transportation to the ER, where he is admitted for pneumonia. After treatment, he is discharged and directed to follow up with his primary care physician. He is not at risk enough to warrant home care, so his continued care is solely in his hands.
Due to his limiting circumstances, (cannot drive, very little home support system, and dementia) he fails to follow up with his primary care physician or properly care for himself at home. His condition worsens, and he is readmitted to the hospital only a week after being discharged. Following ACA regulations, the government does not reimburse the hospital’s expenses for this second hospitalization, resulting in a massive financial loss for the hospital. This has repercussions for patients throughout the community: the hospital has difficulty recouping their losses, making care less affordable and accessible.
The Patient Experience with Synchronized Care
The same man seeks treatment for his fall at an urgent care center. The APRN notes signs of dementia and decides the patient should see an ER doctor. The APRN knows the man cannot drive and does not warrant an ambulance, so arranges transportation to the hospital for him. The APRN also contacts the patient’s family member in this case his sister, to let her know what had happened.
The APRN follows up with the ER and finds the man was admitted for pneumonia. Again, the APRN updates the man’s sister and also contacts his primary care doctor.
When the hospital prepares to discharge the man, the APRN works with the social worker that oversees the discharge planning. The man does not qualify for home care, so the APRN figures out how to work in conjunction with the social worker to ensure the man’s continued care at home. The APRN contacts the man’s primary care physician and explains how to smooth the transition from hospital to home.
Once the man returns home, the APRN assesses his in-home support system. The APRN works with the man’s sister and any other relatives and educates them on what they can do to support the patient’s recovery. The APRN seeks to understand familial relations and make suggestions for care accordingly.
The APRN reconciles the medication ordered by his doctors and his most recent hospital stay with what is in the home and instructs the man and his family on the proper medication regiment. He/she posts magnets and reminders around the home to ensure the medications and phone numbers of the synchronized care team members can be easily reached. The APRN also arranges a follow-up visit with the primary care physician. If needed, the APRN arranges transportation as well. When everything is in place, the APRN stays in touch with the man, his family, and the primary care physician, in order to coordinate care between them and ensure the patient receives the proper treatment.
Because the man has a strong support system and the synchronized care provider has arranged the proper care, he recovers from his pneumonia and is not readmitted to the hospital.
This man’s case is hypothetical, but similar cases are not uncommon: often, patients who do not qualify for home health are still at risk for re-admission. Synchronized, wrap-around care works to resolve barriers to treatment and educates those involved in ongoing care on the role they must play in the patient’s recovery. In this way, high-risk patients can proactively manage their health, resulting in fewer trips to the hospital.