How to prepare patients and families for the reality of ongoing care

By Chief Medical Officer, Stephen Evans, MD

Most elderly patients and their families believe that Medicare will pay for all of their medical expenses, and increasingly their personal needs, in the last two years or so of life. This is only partly true. We have an opportunity to educate patients and their families before getting news that they’ll need to pay for a portion of their ongoing care outside the home setting following a hospitalization.

How do office staff identify patients who need this information? Consider these five basic “domains” of care:

• Medical instability pertains to the progression or change of underlying medical illness. In most cases, this requires communication with the physician or APP seeing the patient.
• Functional status: Is the patient falling, requiring more assistance in their usual setting?
• Memory loss
• Mood (depression particularly)
• Social determinants of health deficits can be assessed by MAs, nurses, and receptionists. Ideally patients with these deficits, particularly if they arrive in a wheelchair or with a walker, are educated by Care Management staff before the next clinical problem (fall with fracture, stroke with disability, or recurrent infection) occurs.
  
  

Talking to patients and families about care after hospitalization

After a hospitalization, your patients may benefit from a short nursing facility stay, either for rehabilitation or for nursing interventions, such as continuation of IV therapy. Keep these caveats in mind when seeing a patient who might require such care in the next six months or so:

1. Patients with pre-existing dementia always experience worsened memory loss with a hospitalization, and usually most of the loss occurring then is permanent; memory scores while in the hospital and afterwards can predict the likelihood of whether someone will be able to return safely home without 24-hour care. (Patients less than 20/30 on a validated dementia score almost never return home safely.) That is why it’s so important to identify patients whose memory loss may worsen with the next hospitalization and consider talking about care issues that are likely to arise.
2. Patients who cycle through the hospital, nursing home, and home health on a regular basis are always approaching a time when they won’t meet Medicare rules to continue that cycling movement. Obviously, patient specifics will vary, but families who may need to start spending lots of money or accessing long-term care insurance should hear about that approaching reality as early and often as possible.
3. Custodial care is very expensive, whether personally (a son or daughter who moves into a parent’s home to provide care) or financially (paying someone to provide intermittent or constant personal care at home, in assisted living, or in a nursing home). Given the high cost, some patients and their families make decisions about care based on what they’re likely to have pay for personally. The earlier you help patients and families consider what “may be coming” around the corner, the more they can prepare. And once they get over the sticker shock, they will thank you!
   
   

HealthTeam Advantage has lots of resources to help clarify these questions as they arise for patients who are our members.