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Transitions in Care

 By Wendy Simons



...I just returned from speaking at the California Association of Long Term Care Medicine conference in Long Beach where the topic was transitions in care.  It is very evident that the health care system for our seniors is often times as confused as the seniors we serve. Despite our best efforts and intentions, there are breakdowns in the communication systems that are as frustrating to the physicians as they are to the seniors.

...I found that the physicians attending the conference share these concerns and often times have reasonable solutions. However, due to HIPAA, the hands of most parties are tied and information does not transfer due to the efforts to “protect” health privacy information. The greatest concern expressed by these physicians was the inconsistency in medication listing for the patients.

...Take for example the individual who becomes ill at home, and is transported to the hospital. Often the listing of medications he/she is taking, is not available. If the individual is unable to express him/her self properly, or the family member is not in the know, the hospital personnel are at an disadvantage as they try their best to gather the necessary information to treat the individual.  The same is true for those transported from a care facility. Medical conditions and medication lists are often sent with him/her, but can become misplaced. If admitted, medications may change or not be available as they were at the facility or home. Upon discharge, there may or may not be a reconciliation of the old medications with the new.

...What lessons are learned from this?  It is critical to have a listing of all prescription medication’s, over the counter medications and supplements that one is taking. The list should include the drug name, dose (i.e. amount in milligrams), and the frequency of the medication (how many taken and at what times). It is also beneficial to list the doctor’s name who prescribed the medication.  This information should be kept on the person (in a purse or wallet) of the individual and updated each time there is a change.  When one is being transferred from a facility to the hospital, the facility should assure the medication information is identifiable and easy to locate. I suggest printing it in a bright color, pink or yellow, so that it is easy to locate in the admission record among the mass of documentation now required in our health care system.

...As a person transitions from home to hospital to skilled nursing to home, so many inconsistencies can occur. Be aware that the physicians are equally concerned about the safest treatment of the patient, but since numerous doctors may be involved in the care, medication history may be overlooked. It is the responsibility of the family or patient representative to assure the physicians have the best information possible to provide for the best outcome. Be an advocate for those who need it most. Navigating the transitions in care is not easy.

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