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Coordinated Senior Care - Aging Wisely

senior care doctorOlder adults with multiple chronic health conditions have an average of 37 doctor visits, 14 different doctors and 50 separate prescriptions each year.  (Read more statistics and this citation: Chronic Illness: The Cost to Society fact sheet.)

This comes as no surprise to those of us who assist elders and their families in navigating the healthcare system.  As care managers, it is not unusual for a client or family to come to us for a geriatric care management assessment to find that the client has five, seven, ten or more different medical specialists.  Many times the client is on ten or more medications as well and perhaps receiving treatment for various conditions at various locations.  One of the reasons a family may seek the assessment is the realization of this fragmentation and resulting problems.

As we age and have more medical conditions needing management, we are at the same time more vulnerable to the negative effects of uncoordinated care.  It is challenging for the patient navigating and coordinating between the various providers.  Failures in communication may lead to inefficient and even ineffective care at times.

As patient advocates, we serve in the role of care coordinator for our clients and their families.  Here we share a little more about that role, as well as some “take aways” that any family member/advocate can incorporate.

A care manager coordinating care makes sure all the pieces of the puzzle are in place…connects the dots so to speak.  This helps to ensure problems do not fall through the cracks and helps patients and families take a step back to ask the questions they need to feel comfortable with decisions about their healthcare.  Often, when a family contacts us one of their primary concerns is the number of tests or procedures taking place and their purpose/goals.  Take away: consider having someone attend appointments with the elder and keep notes as well as help the medical providers by giving them the information they need to understand the “big picture” of the patient.

When someone has multiple conditions and providers, it is impossible to rely on memory and casual communications to relay information back and forth.  Our Aging Wisely care managers have long used an electronic personal/health records system for clients, enabling access and sharing of appropriate information amongst permitted parties.  This information is as invaluable at a standard appointment as it is during a middle of the night emergency room visit.  Take away: use a system to record and track information and communicate amongst various providers (there are numerous electronic personal health records systems available, which have the benefit of accessibility).

Transitions are especially problematic for frail elders, individuals with dementia and persons with multiple medical conditions.  Planning and good communication is imperative during care transitions (such as hospitalization and discharge, moving to a care facility or bringing in care or changing providers).  Take away: get Aging Wisely’s Discharge Planning checklist and check out our website/blog for loads of resources you can use to assist you in a care transition.  Transitions are key times when you may want to consider hiring a patient advocate to coordinate.  Can’t find something you need?  Contact us/send a comment and we’ll help!

Need help today? 

Call us at 888-807-2551


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Our goal is to enable every individual we work with to live the most fulfilling life possible, with utmost dignity, focusing on their physical, mental, spiritual, family and financial wellbeing.