MedCity Influencers, Physicians

3 strategies for how physicians can care for seniors in 2022

With patients choosing to recover and age in the home in record numbers, physicians are being asked to coordinate care with post-acute, home and community-based organizations, and payers at levels never seen previously. This poses a significant challenge for physicians.

Medicare, Medicare Advantage, seniors

Now more than two years into the Covid-19 pandemic, seniors are overwhelmingly choosing home-based care. Based on CarePort’s 2021 data, nursing home referrals are down 20% across the U.S. With patients choosing to recover and age in the home in record numbers, physicians are being asked to coordinate care with post-acute, home and community-based organizations, and payers at levels never seen previously. This poses a significant challenge for physicians, who often lack critical information regarding a patient’s care in other settings and struggle to coordinate care with disparate providers. Below are three strategies for how physicians can rise to meet the challenges of delivering senior care in 2022.

Connect with post-acute and home- and community-based providers

Patients are best served when a bridge exists between their physician and their in-home care providers. Physicians need to communicate with these providers to refer new patients and coordinate the care of established patients. Yet this is hugely difficult to do. There are hundreds of thousands of post-acute and home- and community-based organizations. Communicating with these providers through phone calls and faxes is highly inefficient for overburdened, short-staffed teams in physician offices.

With more seniors requiring in-home care and a nationwide staffing shortage, technology is increasingly connecting post-acute and home- and community-based providers with physicians. Unfortunately, many physicians are unaware such capabilities exist. For example, next-generation referral tools enable physicians to electronically refer patients to in-home providers and to “close the loop” on referrals and ensure patients receive the intended services. By bridging the gap between physician practices and post-acute providers, these new tools can connect historically siloed parts of the care continuum.

Post-acute and home analytics

Visibility and data into how patients are doing in post-acute and home settings can help physicians triage patients – both in terms of determining who is appropriate to recover in the home and to proactively intervene on a patient who may be deteriorating in the home. For example, analytics can now match patients to high-performing post-acute and home-based providers, as well as identify patients who are at rising risk for hospital admission in the nursing home or home.

No analytical tool, no matter how sophisticated, can be a substitute for physician judgement. Rather, the promise of analytics is in augmenting physician judgement and identifying patients who would benefit from further physician evaluation.

Getting care transitions right

As we deliver more care outside traditional settings such as hospitals and physician offices, getting care transitions right is ever more critical. Without the proper care coordination, there is a high potential for patients to “slip through the cracks.” For example, if a patient’s primary care physician is not alerted that their patient was hospitalized, a medication change made in the hospital may inadvertently be discontinued upon the patient returning home.

Recognizing the importance of transitions, the Centers for Medicaid & Medicare Services (CMS) and payers are rewarding physicians for care transitions done right. For example, new measures such as the Transitions of Care (TRC) measure, which became part of the Medicare Star Ratings for the measurement year 2022, incorporates four time-sensitive elements known to mitigate readmission rates. The first two points of transition require the notification of inpatient admission and receipt of discharge information within a day of the event. The other two activities — member engagement after inpatient discharge and medication reconciliation post-discharge – must occur within 30 days of discharge to count toward the measure.

Real-time visibility into where patients receive care is increasingly essential for physicians. Through real-time data exchange and alerts, physician teams can locate and track patients after discharge and ensure high-quality care transitions no matter where patients are receiving care.

Care coordination takes on new urgency in 2022

Healthcare delivery has evolved since the pandemic began, and this transformation will only accelerate in the coming years. Many patients now prefer to receive care in the home, and payers see the promise of home-based care as a lower cost setting of care. However, for care in the home to be successful and persist, high levels of care coordination are required. If care coordination is not prioritized or is conducted in an ad-hoc way, patients and their families suffer the consequences. Families – particularly women – end up shouldering the responsibilities of coordinating care for loved ones, and even then, patients may end up back in the hospital.

The success of home-based care requires a focus on orchestration and coordination. Physicians play a key role, but they need to be enabled with the right tools – connectivity to post-acute and home- and community-based providers, post-acute and home health analytics, and real-time visibility into care transitions.

Photo: imtmphoto, Getty Images

Lissy Hu, MD is the CEO and founder of CarePort, powered by WellSky®, a market leader in care transitions.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.