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Coordinating Care

By Lindsey Getz

Primary care physicians face a challenge when coordinating elders’ care with other physicians who also treat the patient.

As individuals age, a dramatic increase often occurs in the number of specialists they see—particularly in the presence of a chronic illness or condition. While seeing specialists allows a patient to address various concerns, it can also pose challenges. That’s because with so many “cooks in the kitchen,” it can become problematic for the primary care physician to coordinate the patient’s overall care.

Sharon A. Brangman, MD, a professor of medicine and division chief of geriatrics at SUNY Upstate Medical University in Syracuse, says this segregated approach to healthcare is a huge challenge to the optimal treatment of geriatric patients. However, there’s no simple solution since the existing healthcare system isn’t set up for coordinated care. “It ends up taking a lot of effort on the primary care physician’s part to keep things organized,” says Brangman, who is also chair of the board of directors for the American Geriatrics Society.

“The primary care physician needs to know all of the doctors the patient is going to and, assuming those other doctors aren’t in the same health network, needs to make sure those other doctors are copying their notes to them,” she says. “However, if the physicians are in the same health network, and the network is on an electronic health records [EHR] system, then coordinated care becomes much less complex.”

Indeed, the widespread adoption of an EHR system would help greatly in the facilitation of coordinated care. John Bruza, MD, an associate professor of geriatric medicine in the Perelman School of Medicine at the University of Pennsylvania, says that at Penn all of the health network’s subspecialties use the same EHR system. This has made the management of some highly complex patients much easier. “It facilitates almost instantaneous communication with providers,” says Bruza.

In fact, that kind of coordination works so well among complex patients—those seeing multiple doctors on a regular basis—that Bruza says he may encourage certain patients to reconsider an outside specialist they’re seeing in order to try to keep everything within the same health system or network.

“That’s not something I’d recommend for the majority of my patients but for those that are quite complex, I might suggest they consider it,” he says. “I’d say the same thing if a patient was seeing all of their specialists in a different health network but seeing me as a primary care physician or geriatric consultant. If I believe they’d benefit from seeing a primary care physician within their network, I’d suggest they consider it. It can definitely make coordination of care easier.”

Patient Responsibility
Unfortunately, because there are still plenty of health networks that haven’t integrated an EHR, as well as plenty of patients who see specialists among a variety of networks, in the current system much of the responsibility often falls on the patient. Brangman says it comes down to educating the patient on the importance of keeping his or her primary care physician in the loop.

“I’ve had instances where the family calls upon their own specialist and makes their own referrals and never lets me know that they were contemplating a hip replacement surgery or some other major procedure,” she says. “I always tell patients that it’s important they keep me in the loop should they be considering any big medical decision. The same goes for medication. Should a specialist prescribe them a new medication, I ask that the patient call our office and let us know.”

Prescription medications present one of the biggest challenges arising from patients seeing multiple doctors. With different physicians prescribing various medications, it’s critical that the primary care physician be aware of a complete list. “Every time we see a patient in the office, we ask them to bring in all of their medications—prescription and nonprescription—no matter who wrote them,” says Brangman. “Similarly, if a patient has just been discharged from the hospital, we generally see them in the office and do a ‘medication reconciliation’ where we see what medications they were discharged on and make sure those medications make sense. The primary care physician is the most likely to be familiar with the patient’s overall history.”

Patients (or their caregivers) also need to stay on top of their healthcare by requesting copies of procedures and test results and always ensuring that the primary care physician is being copied on any medical notes. “In our office, after every visit the patient also gets an updated after-visit summary that includes a full list of their active medical problems and their current medications,” says Bruza. “I explain to patients that this is a very helpful document to keep with them. In addition, our electronic medical records system allows patients or caregivers online access to a portion of their health record. That’s a great tool as well because they can come home from a visit and print out a summary of their medical issues.”

But in the end, making sure patients recognize the importance of keeping their primary care physician in the loop comes back to patient education. The truth is that many older patients don’t realize that behind the scenes, care coordination isn’t really happening. “One thing I’ve done with my own parents and my patients is to give them some insight on how the health system works. It’s helped them understand the importance of keeping a sort of ‘shadow chart’ of their own,” says Bruza.

“Many patients and their caregivers have a misguided notion that doctors have communicated clearly to one another. It’s common for them to believe I may have spoken to one of their specialists after they visited when in fact I may not have even got that doctor’s medical notes,” Bruza says. “Once the patient realizes that they may need to take some part in ensuring I get the proper notes from their visits with specialists, they start to realize how important it is to be requesting that information.”

While large-scale change takes time, the widespread adoption of EHRs and a move toward better coordination of care is believed to be on the horizon. Brangman says the combined effects of patients living longer than ever and the number of baby boomers entering their elder years should make coordinated care a top priority. “I think the sheer demographics of an aging society simply can’t be ignored,” she says. “There will be no choice but to look at ways to efficiently provide quality care. It’s not going to be a matter of choice. Solutions need to be considered in order to start providing the best possible care to the aging population.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.