ClickCare Café

House Calls & Home Care Are Lonely But Medical Collaboration Helps

Posted by Lawrence Kerr on Thu, Mar 30, 2017 @ 06:04 AM

winterroad.jpgHouse calls are not a core part of my practice as a specialist, although I have made many.

In doing a house call, I think of driving up a snowy road to a decaying-but-loved farmhouse and moving next to a window's light to look at what might be cancer. I am always struck by contrasting feelings of attachment with the patient and family and isolation from the medical environment. Without doubt, seeing my patients in their home amplifies understanding of their challenges. Deeper understanding of their cultural and personal roots is placed front and center. (And, of course, that understanding is a great help, even if it sometimes makes clinical detachment difficult.)

For a doctor, it's unusual to have this level of immersion in patients' contexts on a routine basis. But for people who deliver care in the home -- the caregiver, the aide, sometimes the family -- it is their "normal." They see a developing stroke manifest by a slow degradation in clarity of speech, although it's hard to describe and hard to communicate. They see subtle changes in the nature of a wound that portend massive sepsis. But they are not given the tools or the structure to communicate these observations, hunches, and context effectively.

Medical hierarchy is both very deep, very entrenched, and often with caregivers and home care aides, seen as being at the "bottom." Because of the hierarchy, providers like aides, who primarily give care at home, are expected to carry out orders, not influence the course of care. So they're left with checkboxes and protocols, not tools to share their insight. Often checkboxes and protocols are designed to avoid mistakes, but instead have the unanticipated consequence of communicating nothing because there are not enough boxes to check.

The hierarchy has value in that a chain of command makes orders clear and accountability strong. However, complex situations demand a more complex flow of information. Not just orders from top to bottom, but information "uphill," too. And when information needs to flow uphill, the orderliness of hierarchy makes a strong barrier to responsive and personal adjustment and modification as a vital response to changing condition.

Beyond communication, we need to rely on collaboration where we take the best of everyone in the hierarchy and build a team and a plan. Teams change. Plans change. We need to accommodate, embrace, and adjust to the change.

So, to return to the title of this post, probably the loneliest and most solated work in healthcare is home health care. Changes are observed but it can be an almost impossible job to communicate those changes in the context of the hierarchy. When home monitoring sends a signal of weight change to a central station, that is lauded as a great breakthrough and it is. Then what? The caregiver in the home probably saw a change first and even knows the intervention that is needed. We need to recognize this and empower the change while keeping the entire team involved.

One more reason for doing what we are working so hard to do: getting access for the patient, collaboration for the providers, and use the interactions to teach those who follow us.

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Tags: medical collaboration, healthcare collaboration, homecare, home care

As Long Term Care Gets Intimate & Decentralized, Telemedicine Can Help

Posted by Lawrence Kerr on Mon, Nov 23, 2015 @ 07:30 AM


We're all trained to look for "best practices." If there is a best or better way to do something, we want to know what it is. Many times, though, the excellence of medical care depends on the patient and the context.

The field of Long Term Care is no different. Sometimes an assisted living facility works just right. Sometimes aging in place is the ultimate. Sometimes it's senior co-housing. What works best in Long Term Care is for each patient to have access to the kind of care that works best for him or her. People want and need different things.

That said, one trend is for senior care to be as personalized as possible, as intimate as possible, as small-scale as possible, and as aligned with the individual's life as possible. That's why we see so much caregiving happening in different, patchworked contexts.

That's also why we see this trend that the New York Times recently covered, of small residences that still have the medical and caregiving resources that many older people need. It's a balance of medical help that can only come from an institutional setting, with the human need for more individualized settings. For instance, Our Family Home is a small, home-style setting for groups of patients with Alzheimer's or dementia. And The Green House Project is a network of homes that are created to support patients' needs while also feeling like an individual house.

There are some important challenges with these models, though. Because the settings are more dispersed, for specialized care to be happen, patients will often have to travel to a doctor's office or a hospital. Or, the specialist will need to travel to multiple facilities to complete the rounds.

So what's the answer, when decentralized models are great but there are geographical challenges with access to care? Well, it's a pretty simple answer, actually. We believe that telemedicine platforms can allow less centralized, more intimate, more personalized housing solutions to be viable. By allowing healthcare collaboration across the continuum of care to occur -- on the schedule and in the location of the people involved -- these models become a lot more practical, even in complex medical situations.

These are 3 key ways telemedicine supports seniors in getting the Long Term Care that works best for them, even in decentralized models:

  1. Telemedicine makes it so more people can be involved in care, while not interrupting "compassionate continuity." 
    It is best for people to have continuity in the people who care for them. However, the complexity of many patient's conditions require nurses, aides, specialists, other specialists, and therapists to collaborate on a single case. A platform like iClickCare allows these people to contribute while also allowing the trusted aide to be the primary person in the patient's life.

  2. Using photo and video for healthcare collaboration is key in Long Term Care.
    A good telemedicine platform makes using photos and videos more practical -- and HIPAA safe.

  3. Healthcare collaboration --  at a distance -- makes homecare more financially sustainable.
    If specialists have to make increasing numbers of house calls, because there is insufficient technology to allow collaboration at a distance, homecare becomes less viable. If these trends continue, we'll need to find ways for the people providing the home care to be supported by other medical providers, in efficient and effective ways.

If you're part of changing how Long Term Care happens, we want to help. You can download our free ebook on transforming Long Term Care here:



Transforming Long Term Care Through Telemedicine

Photo used under Creative Commons rights from fairfaxcounty on Flickr.

Tags: telemedicine, Telemedicine and HIPAA, long term care, healthcare collaboration, homecare, home care

3 Healthcare Collaboration Insights From Unpaid Caregivers

Posted by Lawrence Kerr on Thu, Oct 01, 2015 @ 07:30 AM



For all of the medical providers involved in Long Term Care, there is one medical provider who is often unseen and unheralded: the unpaid caregiver. 

The New York Times has done a beautiful job recently painting a picture of all of the different faces these caregivers can have. She is the niece of the widower. He is the son who lives with the filmmaker father. They are the aides and volunteers from residential facilities, rehabilitation centers, and nonprofits.

According to the Institute of Medicine, unpaid caregivers provide 90 percent of long-term care for the old or disabled.

These caregivers are an integral, indispendale piece in the patchwork of care for people -- whether older people or people with chronic conditions. These might be individuals within a residential Long Term Care setting or people living at home. For example, Mr. Sorensen, 90, relies on regular visits from his niece, weekly visits from three home attendants, and biweekly visits from a nonprofit that sends volunteers. 

Because so many different people are involved, with different skill sets and levels of investment in the individual's care, it becomes a crucible of healthcare collaboration. It's a situation, for most people, where medical collaboration is both acutely necessary and uniquely challenging.

3 Unique Lessons About Healthcare Collaboration That Unpaid Caregivers Demonstrate:

  1. Coordination of care may be the most powerful influencer in a good outcome.
    Because there are so many different people involved in each person's care -- and with some of those people unpaid -- coordination of care becomes critical. Each person has a piece of the puzzle but there will always be gaps (for instance if an aide can't come in). So it is imperative that there be a mechanism for communication. When coordination doesn't happen effectively, there can be confusion about medication, care that doesn't adjust up or down with abilitiy changes, and there can be actual gaps in attention.
  2. No one is in just one kind of care context.
    The New York Times describes a common situation, from the perspective of Ms. Kornblum, a woman caring for several elderly family members. "It was part of her mother’s regular rotation, Ms. Kornblum said: assisted living to intensive care to rehabilitation, then back to assisted living." These resources are deployed at different times for different reasons -- but the patient, the person, must be cared for across all of them. The information that the rehab center (for instance) has about the patient must be transmitted to the caregivers when the patient is discharged. That's why communication and healthcare collaboration is key. 
  3. There just aren't enough resources. 
    Home healthcare tends to be slightly less than people need, so those hours and dollars need to be maximized. We've seen in home-based healthcare settings for example, that if aides are empowered, through the use of telemedicine, to access opinions from other providers and specialists, then resources are much more efficiently used.

Ultimately, those involved in Long Term Care -- whether paid or unpaid caregivers -- are some of the most creative, intrepid providers around. They face unique challenges and meet them in ways that provider all medical providers with helpful insights. 


If you are involved in Long Term Care, download our free ebook on the most supportive, immediate things we believe can help transform it:


Transforming Long Term Care Through Telemedicine

Tags: long term care, healthcare collaboration, homecare

5 Reasons To Use Photos & Videos In Long Term Care

Posted by Lawrence Kerr on Wed, Aug 12, 2015 @ 07:00 AM


Long Term Care Facilities Share Challenges with Outposts

Credit: Wikipedia, Une compagnie de la 2e legion sur les champs de mars à Paris en 1836 par Auguste Antoine Masse

Are you in the French Foreign Legion? Probably not, but I would bet that you, like me, have felt like you sometimes work in an outpost. (Think: Lewis and Clark, Roald Admundsen, Davey Crockett.)

You are more fortunate. You have the telephone, so you are not so alone, right? You make a call, and bravely stand up to an attack of telephone tag. You describe clearly the change. You might hear five responses.

  1. "Can't be, I was just there yesterday."
  2. "Are you sure?"
  3. "I believe you, I wish I could see it."
  4. "She didn't have it when we sent her to you or admitted her."
  5. "This shouldn't happen, I need to contact my loved one's lawyer."

It's always tricky to describe something accurately. And it's even harder to describe a change or motion. 

In the simple case of wound or rash, you can say "it is red" or "it has an exudate" or "it has granulation tissue." Technology can't capture everything that you can see as the observer, but a photo can show color, size, and texture. Plus, stored images can be compared to support analysis of changes. 

In the simple case of a change in gate or speech, describing something as dysarthria, limp, lurch or foot drop does say something, but are not as convincing as a video clip. And again, stored videos can be compared to help monitor shifts over time.  

So the 5 reasons to use photos and videos (via a telemedicine platform) in long term care or skilled nursing facilities are to:

  1. Describe changes in the patient
  2. Communicate clearly
  3. Resolve doubts that can hinder execution of treatment plans
  4. Document on-admission disease
  5. Communicate with the family

I am dumbfounded why legal counsel often tells their long term care clients to not take pictures. Ignoring a problem never improves it, and sweeping it under the rug of paper records brings ill will. Further, with the right technology, there is no reason for HIPAA to be challenged. 

Why not have happy families, satisfied providers, documented change, and good records for education and reference?

You have a hard job in the outpost. Help you and your staff make it easier. 

And if you're working on implementing changes like these in your long term care facility, our ebook may help with staying compliant, decreasing costs, and improving care"  

Transforming Long Term Care Through Telemedicine


Tags: homecare, senior care, workflow

3 Shifts in Medicine (and How It's Paid For) You Need to Watch

Posted by Lawrence Kerr on Tue, Jul 07, 2015 @ 07:00 AM


Healthcare in the US is almost unfathomably complex. Plus, it's always changing, such that it can be very hard to notice trends in any useful way.

However, we are at an especially volatile and important moment in medicine, with the reverberations of the Affordable Care Act still playing out. Just in the past few weeks, I've noticed a few trends that I think every ACO, every hospital, and every medical provider should have their eyes on.

3 shifts in medicine that will probably impact you in the next year:
  • Insurers will be demanding "more" from providers and hospitals.
    On one hand, insurers are squeezed by higher-than-expected costs of the newly insured. Many are now requesting rate increase approval from the government. As the New York Times reports, "The rate requests, from some of the more popular health plans, suggest that insurance markets are still adjusting to shock waves set off by the Affordable Care Act." On the other hand, many insurers are merging, which gives them more leverage over hospitals and providers.  The pressure to increase revenue and cut costs, combine with increased power from mergers may well add up to more demands on providers and hospitals.
  • Non-traditional care contexts are becoming the norm.
    Because of shifts in what is able to be reimbursed under the Affordable Care Act, there are new delivery mechanisms being pioneered. For instance, there is a current boom in diet clinics, due to ACA reimbursement for obesity consultations and treatment. It's likely that as care outside of doctors' offices increases (with other medical providers being the ones actually interfacing with the patient), healthcare collaboration (especially using telemedicine tools) will become more important. Collaboration will need to happen more, and across the spectrum of care, in order for patients not to fall between the cracks.
  • Home care is a growing segment of medicine, and we're (mostly) not doing it well.
    Data is beginning to suggest that there are more homebound people than ever before, and they're sicker. Plus, there are more caregivers who are older family members and need support themselves. This type of dynamic means that medical providers are responding, and finding ways to provide care at home. For instance, there is a growing group of geriatrics practices that make housecalls. And if those housecalls have to be made by specialists because there is insufficient technology to allow collaboration at a distance, that's going to be unsustainable. If these trends continue, we'll need to find ways for the people providing the home care to be supported by other medical providers, in efficient and effective ways.

For decades, medical providers had the luxury of ignoring macro trends. These days, however, I think that we ignore these dynamics at the peril of ourselves, our practices, and our patients. For us to act with wisdom, sustainabily, and in service of good medicine, we must act with these things in mind.

And really, that is more of a privilege than a burden.


To learn how iClickCare can help you adapt to these shifts, click here: 


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Tags: accountable care, homecare, ACO, affordable care act, home care, affordable care act compliance, insurance,

Why "House Calls" Need Telemedicine -- Especially in Senior Care

Posted by Lawrence Kerr on Wed, Apr 30, 2014 @ 09:09 AM


homecarenurse resized 600

It goes without saying that in the 3+ decades that I've been a doctor, I've seen a lot of changes in the medical profession. Many of these changes have been difficult, of course -- plummeting time with patients, ludicrous paperwork, and illogical financial incentives, among them.

From time to time, however, I see big changes in medicine that are deeply positive. The most powerful and progressive changes are happening through:

  • Thoughtful integration of simple "good medicine"
  • Alignment with current political and financial realities
  • Creative use of existing technologies.

The "return of the house call" is one of these fantastic trends. For a long time, it has looked like the house call went the way of the doctor's bag -- a nice idea but not something that fits our current reality. Recently, however, there has been a resurgence in house calls and home care for everything from palliative care to wound care to concierge medicine.

The return to medical providers visiting patients at home is supported by common incentives and the current political climate. For instance, the Affordable Care Act penalizes readmissions within 30 days of discharge; integrated home care is seen as one way to decrease readmissions and improve outcomes. Also, a focus on a "fee for performance" rather than a "fee for service" model, and an overall push to cut costs, has encouraged the "house call" approach. Finally, as the New York Times reports, "Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment."

Because home care is removed from the traditional hospital setting, medical collaboration is crucial to successful home care.

For instance, a 2007 study, by Dr. Richard Brumley and colleagues, found that palliative care patients who received in-home interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving standard home care. This resulted in lower costs. For house calls and home care to really work, they need to incorporate providers across specialities and across the continuum of care. Providers must collaborate because it is not efficient for every provider to visit the patient at home, but a home visit can be a crucial part of an integrated approach. And telemedicine is the key for this kind of medical collaboration to be effective, cost-efficient, and time-sensitive.

We've found that house calls and home care are especially powerful when the following components are in place:

  • Healthcare providers at all points in the spectrum are included.
  • Multiple specialties collaborate on a single patient.
  • Tools like store-and-forward telemedicine are used to enable rapid and time-sensitive consults. 
  • There is a focus on medical collaboration in service of good patient outcomes (rather than a simple "counting" of visits or services.) 
What has your experience been? Have house calls and home care been a part of your approach to patients? What key elements have you noticed. We look forward to hearing, in the comments below. 

For our Quick Guide on medical collaboration, click here:

ClickCare Quick Guide to Medical Collaboration

Image courtesy of myfuturedotcom on Flickr, used under Creative Commons rights.

Tags: telemedicine, medical collaboration, homecare, ACO, affordable care act, home care

How Telehealth in Assisted Living Decreases Isolation Challenges

Posted by Lawrence Kerr on Wed, Apr 16, 2014 @ 08:23 AM

seniorinbed resized 600

For older people in our country, particularly in today's economy, it is hard to put together a care plan that balances good medical care with needs for independence -- and interdependence. Costs are higher than ever and with people living longer, more productive lives, these decisions are increasingly important.

An Assisted Living Community can be fantastic, but if seniors wait too long, it can be hard to get into one. Living at home supports independence but can be isolating and is very expensive if there are medical needs to attend to. And skilled nursing facilities may be a higher level of care or cost than many people are ready for.

There are some trends showing that the number of Americans living in multi-generational households is increasing dramatically. NPR's fantastic series on these families is illuminating and puts a face to the 51.4 million people who are now living together in this way (the highest rate of Americans living inter-generationally in modern history.)

However, despite the increase in families living in multi-generational homes, and despite the growth of Assisted Living Communities, most older Americans are living alone -- and isolation is often a part of their experience. For these individuals, isolation does not just affect happiness and well-being. Isolation in older age also makes medical care very challenging. For instance, a study cited by NPR shows that "people with dementia who are cared for at home are more likely to get unwanted treatment than if they are in a nursing home."

Living at home can be great for many things, but isolation and increasing medical demands require sophisticated management.

For instance, let's take the case of Edna, an 89-year-old firecracker of a woman who loves crochet, seeing her grandchildren, and baking pies with unusual flavors like vanilla-blueberry-lavender. Edna has been in great health her whole life, lives in an Assisted Living Community, and has a caregiver who stays with her during the day. Her caregiver, Librada, is extraordinary, loving, and adored by Edna. But when Edna has a question about a sore, pain, medication, or shortness of breath, Librada doesn't have the medical background to make a call. So Librada usually contacts Edna's family (who can be hard to get ahold of, with burdensome work schedules), then takes Edna for a just-to-be-sure check with one or more physicians. These checks often turn into round-robbins of medical visits, at the end of which Edna is exhausted, frustrated, and feels worse than ever.

So what is the solution for seniors living at home, receiving home-care, living in Assisted Living communities, or even for those in skilled nursing facilities? We're finding that Store-and-Forward telemedicine can play a key role in achieving these goals. By using this telemedicine platform for coordination of care and medical collaboration, the people and providers caring for seniors can coordinate in ways that break through isolation, limit transportation, limit unnecessary medical visits, and manage long-term conditions in sophisticated ways. 

We think that any solution for older patients should prioritize 3 things: 

  • Limiting unnecessary visits to medical providers
  • Ensuring coordination of care among caregivers, family, and medical providers
  • Sophisticated management of conditions that take into account the patient's priorities, lifestyle, and end-of-life plan. 
When Skilled Nursing Facilities or Assisted Living Communities use telemedicine, the platform allows providers like aides and caregivers to consult with physicians, nurse practitioners, and specialists -- which means better care and integrated care coordination. For the providers, this coordination means dramatically decreased costs. And for Edna, access to telemedicine would have meant faster and easier communication with her family, the possibility of visiting the local community center and having an aide consult with a physician -- meaning she's back home, with peace of mind, before lunch. And that means more time to bake pies or to be with the newest grandkid. 

Get the information on telemedicine and whether it can work for you, here:

ClickCare Quick Guide to Telemedicine
Image courtesy of moregoodfoundation on Flickr, used under Creative Commons rights.

Tags: medical collaboration, coordinated care, assisted living facilities, telemedicine solutions, homecare

Care coordination that wasn't, or is CYA important?

Posted by Lawrence Kerr on Wed, May 30, 2012 @ 07:58 PM

 A missed opportunity for homecare? A prevailing attitude? A broken system?

Which, or all?  Why did medical collaboration not happen?  We have our opinions, but, we want to know yours. We know what we would do differently. What would you do?

A near transcription of a true event this past weekend (names changed)...

Scene:  Saturday, 1:07 pm, Physician hears: "Beep, Beep, Beep"

      Physician reads beeper: "Melissa - Homecare at Home. Plz call ASAP. 555-555-5555. Dr. Pollard's patient. Wound pink."

      Physician calls: This is Dr. Specialist calling back.

      Nurse: Thanks for calling. Dr Pollards's patient had surgery and it looks pink around the wound.

      Physician: Pink?

      Nurse: Yes, pink.

      Physician: When was the surgery?Care coordination takes back seat to reporting for the provider, not the patient

      Nurse: I am not sure, I was not here last week, but I think it was a week or two ago. Maybe 9 days.

      Physician: OK, where is it pink? Is there a temperature?

      Nurse: She didn't tell me the temperature, just said that the wound area was pink.

      Physician: How pink? Is it red? What part of the wound?

      Nurse: I don't know, I am the office nurse. This was called into me by the nurse in the field.

      Physician: Did it change? Is it worse? Is the nurse availaible? I can see the patient in the Emergency Room.

      Nurse: No, she has left for the day, and said she would see the patient in the morning. We just wanted to inform you. FYI.

      Physician: FYI?

      Nurse: Just wanted to inform you.

      Physician: FYI or CYA?

      Nurse: Unfortunately, we all have to do it.

Let us know your thoughts. 

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Tags: health care, coordinated care, collaboration, homecare, healthcare, home care

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