The problem with home health care communication

Home health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially homebound due to frailty or illness.

But it often feels surprisingly hard to synergize with home health care.

The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)

Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.

And things get even more complicated when it’s a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.

Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).

I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And, on the other hand, she had a fungal rash in her groin, under her incontinence brief.

I prescribed an antifungal cream to be used twice a day for two weeks.

Now it’s been three weeks, and the pharmacy is requesting a refill.

Well … what’s going on with that rash?

What I want to do is send an email to everyone who is involved and might know something. That means an email that would include:

  • The patient’s son, who visits weekly. He’s not a medical expert but he has the most at stake in ensuring that things are checked up on, plus I had him take a look at the rash when I visited.
  • The home health agency RN.
  • The paid home aides; I strongly urged them to start keeping a log of the patient’s skin condition at my last visit. (Is that part of their job? Should it be? Who knows.)
  • The facility RN, who is supposed to keep tabs on things when residents have active health issues, and who helped recruit home health care to the situation.
  • The pharmacy, to tell them why I’m not renewing the medication right at this moment.
I would also like to loop in the primary care doc, but her patient hasn’t been able to come in to see her for a while, so she is the least actively involved member of the care team at this particular moment.

The great thing about email is that you can address it to several people, and when someone replies everyone else can see the response.

The bad thing about email is that it’s not secure. It is really not an option.

So what am I left with? The doctor’s old standbys: the phone and the fax.

Oh sure, someone out there has developed care coordination software that includes secure messaging.

But if we are not already all subscribed to it (which seems unlikely, unless you consider people working in an integrated care system), it’s really not usable unless someone wants to go through the hassle of getting each individual player subscribed.

So fax it is. Fortunately, my EMR allows me to associate a given patient with a variety of other providers (and their fax numbers). It’s still a minor pain to fax a message to several different people, but it’s faster than calling them all.

By the way, I do occasionally call home health care agencies and ask to talk to the nurse. They are usually so surprised to hear from me, because most doctors never try to coordinate much.

What came first: the chicken or the egg?

What will come first: the communication framework or the desire to truly coordinate care?

Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech.  She could be reached on Google+.

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