As healthcare providers, we have a responsibility to ensure that all patients, regardless of their background, receive the best care possible. However, the current healthcare system has failed to address the diverse needs of patients, especially for seniors transitioning into post-acute care settings. Now is the time for us to reimagine healthcare delivery and empower patients to take an active role in their lives.
As two doctors who have experienced poverty and plenty; urban and suburban, rural and city life, we are intimately aware of the pitfalls that can befall senior patients while they are transitioning into post-acute settings. Our background in primary care, outpatient care, hospital care, end-of-life care and critical care gives us a unique understanding of how miscommunication in the medical system can lead to negative outcomes for patients. But this vantage point also allows us to provide a unique view on how to increase the efficiency and deliver better service to the patient, which we believe is a goal we all want to achieve.
Patient-led care is a crucial aspect of this new approach. This means putting patients at the center of decision-making and providing them with the information and tools they need to make informed decisions about their health. While we always say that patients are the center of what we do, fragmentation and shifting priorities can make true patient-led care difficult to achieve.
One of the easiest ways to establish the patient-centered model is to talk with patients instead of at them and provide them with the information they need to understand their healthcare options. This involves asking patients what their goals are and working with them to achieve those goals. Some patients may want a longer life while others want a better quality of life. Each patient has their own set of priorities that aren’t always being addressed in the care they are currently receiving.
When we take our car to the dealership for repairs, we often get a printout of issues to prioritize. By using a red, yellow, or green system, we, as a consumer, can easily understand what may be wrong with our car and determine what needs the most attention now and what can be addressed later. Taking the same approach in healthcare – and clearly prioritizing the needs of patients can help them to better understand their own needs and prioritize follow-up management without feeling overwhelmed.
Outside of the doctor’s office, insurance companies can also play a role in empowering patients. Patients are easily overwhelmed, especially when faced with tough decisions. Patients need specific and clear information about their care, including costs and the consequences of not taking their medications. With this information, patients can gain a sense of control over their health and make more informed decisions. Patients who are involved in their health and understand the healthcare system are more likely to adhere to their treatment plans and achieve better outcomes.
This is especially true during the period of transition of care from one center to the next. The handoff from one medical professional to another is often not as collaborative as it could and should be. Specifically, patients’ transitions from the hospital to the home can be complicated, and their primary care physician may not always be involved in the process. Patients may not know what they don’t know. They may not be aware of what information to share with their larger provider team upon discharge or what questions to ask. The challenge is to identify and mend these knowledge gaps and further enhance coordination between healthcare professionals to ensure that patients receive the best possible management.
One way to improve this transition of care is through better and more thorough communication with the patient and documentation. For example, patients may be discharged from the hospital without clear explanations as to why a certain medication was stopped or changed. Without detailed documentation, their primary care provider may not have insights into the issues either. Upon discharge from the hospital many patients are given orders for lab work, yet no health professional owns that process, and at times the lab work falls through the cracks. Leaving the patient unsure and confused when no one follows up on it.
This is where patient navigators can be indispensable and help guide patients through the healthcare system. We often get bogged down by rhetoric over the cost and efficiency of patient navigators. However, in some sense, patient navigators do not always have to be clinically trained. Even community volunteers or family members who are focused on making sure that patients receive the right information, ask the right questions, and receive the guidance that they need can serve in this role.
The time is ripe for a redesign of healthcare delivery. Through patient education and care navigation, we can empower patients to take an active role in their healthcare, improve outcomes, reduce costs, and provide better care to all patients.