My field, of plastic surgery and reconstructive surgery, has always been one of innovation and even experimentation. So much of the innovation that has happened over the ages is innovation done with and for patients. Some people call these patients guinea pigs; some people call them pioneers; others simply call them valued patients.

Recently, an upcoming movie caught my attention. It's called “The Guinea Pig Club” and is the the story of Sir Archibald McIndoe, a New Zealander working in Britain in World War II who cared for the disfigured using classic plastic and reconstructive surgery techniques (read 4000 BC in India) as well as inventing and systematizing his own.

He worked at Queen Victoria Hospital in East Grinstead, England. He was the student and cousin of Sir Harold Gilles. Dr. Gilles' seminal work was related to World War I. (Interestingly Dr. McIndoe was a teacher of my Chief of Plastic Surgery, Dr Peter Randall. The techniques and the care have certainly been passed on.) The name of the film is the name of a group of patients. To belong to the club, born in a pub, was The Guinea Pig Club. The membership requirement: have had a number of procedures performed by Dr Mcindole. A look at the dramatic pictures demonstrates the fact that a “number of procedures” could easily be counted in scores and hundreds. The club's members supported each other both during and after the war.

Dr. McIndoe's work brought up a number of really interesting lessons and insights for me, both as a surgeon and as a founder of ClickCare. I find the principles of total patient care (now called care coordination, care across the continuum, and care management) fascinating, inspiring, and satisfying.

True medical care has always been about care coordination, not just interventions. 

Collaboration and care coordination extend beyond the institution’s walls -- whether that is long term care, the hospital, or the doctor's office.

For instance, a particularly amazing (but, on reflection, maybe not surprising) aspect of Dr. McIndoe's work was his effort to ensure that each patient also had the work he needed to make a life. (See this video, starting at 49:55.) To me, that is care coordination down to the roots and what we are passionate about making happen for everyone, everywhere.

Care involves more than the patient.

Dr McIndole worked with the local community to teach and help them look past the physical defects. Because of these efforts, East Grinstead became “the town that didn’t stare”.

Support and community is the foundation of health. 

A crucial part of these patients' success was related to their "pub club" through which they provided each other support and understanding. A condition that could have isolated and dominated these men ended up being connective and being the basis for their growth and flourishing after the war.

We're proud to be part of the legacy of Dr. McIndoe -- both in his valuing of innovation, and in his holistic way of pioneering health for his patients. We applaud his efforts as well as those of his patients -- just as we applaud all of the pioneers and "guinea pigs" who innovate with iClickCare every day. 

Click here to be a pioneer and try iClickCare for free for 14 days:

It's no secret that caregivers often sacrifice their careers, happiness, and wellness for those they care for.

When caregivers are caring for parents, elderly friends or relatives, or children with long-term disabilities, those sacrifices can be almost insurmountable. The care only builds; the complexity multiplies; and the sorrows often increase too.

The flip side of this reality is that the Long Term Care that many older patients receive is characterized by being:

• Often one step behind. 
  To protect independence and limited resources, care often lags slightly behind the individual's needs.
• Carried out by a team of people with different skills and perspectives.
  Whether it is a team of sibilings or a team within a Long Term Care facility, the team providing care in these situations is made up of people with different depths of training, different perspectives, and different abilities to communicate.
• Underresourced.
  There are very few situations in which it feels like the resources available for Long Term Care are those that are needed. 

One caregiver in the recent New York Times piece talked about the Family Medical Leave Act, saying that the ability to take three months of paid leave would be transformative, since "If you had a few siblings and each of them could take three months, you could care for a person with dementia." To us, it is a sobering thought when the best-case scenario is such fragmented care that a different individual, connected to other caregivers only by hit-or-miss phone calls, would be caring for a patient for weeks of months at a time and then trading off.

We believe that in any care situation in which the care is patchworked -- provided by multiple caregivers in ways that default to uncoordinated -- healthcare collaboration needs to be intentional and it often needs a technology solution. So many times, playing telephone tag just won't cut it. And sharing photos and videos becomes essential. 

That's why we advocate for the use of a telemedicine solution to support healthcare collaboration among Long Term Care providers. When a telemedicine solution allows caregivers to share information ("Did Dad have a negative reaction to this pill?") with others on the team, and asynchronously (so team members don't all have to be available at the same time), then things can start to work. When team members can share pictures and videos, care gets more sophisticated and less invasive -- outcomes impove.

We don't need robots (yet), or videoconferencing, or even telemedicine medical visits. We just need to support these hardworking teams in communciating and collaborating with each other -- for the good ofthe person that they're caring for, not to mention the good of the caregiver's job and life.

We really value those who provide Long Term Care --  this ebook may help you find easier ways to collaborate with the other caregivers on your team:

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:

I'm a person who likes to do things the right way. My daughters joke that they would ask me for a plastic cartoon character lunchbox and I would buy a functional, long-lasting, man-sized metal lunchbox with a quart thermos. (I, of course, defend myself by insisting it's always better to pay for the high-quality option.) 

That said, I am given pause by the healthcare community's insistence that:

• The expensive option is always the better option
• Multi-million dollar studies yield better information than common sense
• Decades-long technology implementations have any chance of working in our fast-changing world.

For instance, researchers from the University of Missouri recently did a $14.8 million study (funded by the Centers for Medicare & Medicaid Services) to look at the feasibility of implementing Health Information Exchanges (HIEs) at 16 long-term care facilities. Many of the facilities proved to have insufficient technology to implement the HIE plan.

The idea of implementing HIEs in long-term care facilties is excellent. The work is aimed at reducing avoidable re-hospitalizations among nursing home residents. When older adults transfer between nursing homes and hospitals, inefficient and unclear communication between the organizations can hinder patient care, reported the principal investigators in the grant, so they were looking for better ways for providers to communicate.

That said, $14.8 million dollars later, no collaboration had taken place, rehospitalizations hadn't changed, and the HIE plan is so burdensome that this kind of study (and heavy technology setup) is necessary.

Sometimes a notebook and pen are better for taking notes than a Macbook. And sometimes a simple telemedicine collaboration between individual providers is better than an integrated HIE implementation -- especially for long-term care facilities. I get frustrated when I hear that these facilities don't have the appropriate technology, since iClickCare operates on any smartphone or PC. 

The goal itself is simple, according to Greg Alexander, associate professor in the MU Sinclair School of Nursing: “Ultimately, we want to facilitate a way for staff members to communicate safely and securely about patients’ health. We want to prepare nursing homes to communicate externally as well as internally so that care transitions smoothly and patients have better health outcomes.”

There are certainly complexities in acheiving that goal. However, we do wonder whether a simple approach might ultimately be better than a complex implementation. Could much of what they want to achieve happen by giving providers more time per patient? By creating more spaces (physical and virtual) for providers to talk to each other? How about through telemedicine consults using a healthcare collaboration platform (on existing PCs and smartphones) like iClickCare?

We don't have all the answers, but we do believe that a simpler answer now is usually better than a more complex answer later.

Looking for a simpler ways to support your Long Term Care facility in improving outcomes, using the technology you have? Get our free eBook:

We heard a story recently about a day program for older adults called the Wellness and Arts Center at Iona Senior Services in Washington, DC.

This is the type of thoughtful service that is run all over the country by caring providers. It's for people who can still live on their own but need or want help, companionship, or meaningful activities during the day. It's one of those ordinary, extraordinary social services that are being created day in and day out.

We happened to hear about this program recently, though, and we were inspired about a couple of the specifics. These lessons resonated with us as important practices in long term care, and in healthcare collaboration (especially using telemedicine) in general.

3 healthcare collaboration lessons you can take from this adult day services program:

Involve the whole family.
In the case of Vivian Weeks, she was involved in her care, as was her niece, her care givers, and other family members. We created iClickCare to be intentionally inclusive. If you're looking for a telemedicine platfrom to support healthcare collaboration, look for one that gives you the ability to effectively include the family in the collaboration group. 

Prioritize connection and communication.
Just as the participants in the Iona program need human companionship during the day to be happy and healthy, medical providers need to communication with each other. We've known this: research shows that people with strong ties to family and friends have a 50% lower chance of dying during a given period. Similarly, human connection can help medical providers prevent burnout. Medical care -- especially long term care -- can be isolating, so you have to intentionally seek out connection. 

Good long-term care attends to happiness, too.
At Iona, they have art therapy in addition to physical therapy because our abillity to thrive goes beyond just the "medical" aspects of our care. For that reason, we encourage iClickCare users to involved doctors, nurses, but also teachers and therapists into the collaboration for a given patient. Just as good long term care also cares for the social components of a patient's wellness, we believe that a good collaboration platform should support the collaboration of all of the people who contribute to that wellness.

Interested in using telemedicine for healthcare collaboration in long term care? Get our free ebook here: 

Photo used under Creative Commons rights from gazeronly on Flickr

Our colleagues in long term care facilities make heroic efforts at communication and coordination. But when institutions don't use the same EMRs and there are no mechanisms for collaborating, it can become almost impossible. 

Managed Care, ACOs, and Pay for Performance systems have all been circulating in our world for years now. But for many hospital systems and long-term care facilities, adoption and management of these practices has been uneven. And research is showing that some ACOs are floundering to succeed in this new system.

That is about to change, one way or another. Managed care and pay for performance are here to stay, especially in long-term care settings.

Recent reports document that Medicare wants 30% of all payments to go through models like ACOs by the end of next year, and 50% by the end of 2018, up from about 20% now. Of course, there are already incentives and for performance in place, such as penalties for hospitals when patients get readmitted. These nudge providers to improve care, even if they’re still getting paid in a traditional fee-for-service system. The government wants 90% of all Medicare payments to include such incentives by the end of 2018. 

The government's first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016.  Then, alternative payment models need to get to 50% by 2018. So what does this mean?

In alternative payment models, providers are accountable for the quality and cost of care for the people and populations they serve. This of course moves away from the old way of doing things, which amounted to: “the more you do, the more you get paid.” In a Patient Centered Medical Home model, instead of doctors working separately in their own silos, care coordinators oversee all the care a patient is getting.  That means patients are more likely to get the right tests and medications rather than getting duplicative tests, procedures, etc. These medical homes typically offer patients access to a doctor or other clinician 7 days a week, 24 hours a day including through extended office hours on evenings and weekends.

The second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018. Most providers will be tying at least some of their payments to quality and value— even those who are not yet ready to fully transition. Providers will need to link nearly all payment to quality and value, in some way, to see that we are spending smarter. 

As Murphy-Barron's and Fitch's paper summarizes: "Provider organizations need to be aware the managed long-term care plans are funded using a capitation mechanism in which they receive a lump sum per member from which they must pay most long-term care and other ancillary expenses. The risk shifts from the Medicaid program to the plan. Running a successful managed long-term care plan therefore requires significantly more investment in risk management, financial management, and strategic planning than do fee-for-service arrangements."

We're, of course, always advocating for the use of "good old fashioned" common-sense medicine as well as savvy use of technology to support these changes. But the one thing we know for sure is that it will take all of our efforts to find the way forward. 

Take a look at this 60-second video to see why we think telemedicine can help: