House 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.

Help us help you. Try building true collaboration into your workflow.

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:

 

 

Photo used under Creative Commons rights from fairfaxcounty on Flickr.

 

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:

 

 

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"  

 

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: