Continuity of Care

The days are long gone when one doctor, with the help of a nurse, provided all the health care a person needed. Now, older people are likely to see several health care practitioners. They may receive care from doctors, nurses, nurse practitioners, physician assistants, pharmacists, dietitians, physical or occupational therapists, social workers, and nurses' aides. They may have several doctors, each specializing in one organ system or problem.

Older people are also likely to move from one place of care to another. They may receive care in a doctor's office, in a hospital, in a rehabilitation facility, in a board-and-care facility, in an assisted living facility, in a nursing home, or at home. At the end of life, they may receive hospice care.

Ideally, all people involved in a person's health care, including the person receiving care, communicate and work with each other to coordinate health care. Also, all should agree on and understand the goals for health care. Then, changes in practitioners and places of care would occur smoothly, without disrupting care. This ideal is called continuity of care.

As worthwhile as continuity of care sounds, it is not always easy to accomplish because the health care system in the United States is complicated and fragmented. Once people enter the health care system, care seems to happen automatically, according to rules they do not understand and cannot change. So many health care practitioners are involved that if people have questions, they do not know which practitioner to ask. As a result, people may feel like a stone rolling downhill, with no control over what is happening or where they will end up.

People can help improve the continuity of their care. For example, they can learn more about what can interfere with continuity, how the health care system works, and what the system is doing to improve continuity of care. This information can help them take a more active part in their care.

What Can Interfere With Continuity?

Having so many practitioners at so many places may disrupt the continuity of a person's health care. For example, one health care practitioner may not have up-to-date, accurate information about the care provided or recommended by other practitioners. That practitioner may not know who the other practitioners involved are or may not think to contact them. Information about care may be miscommunicated or misunderstood. The person receiving care may mention an important detail to one practitioner and forget to mention it to the others. If the practitioners involved do not have complete, up-to-date, and accurate information, inappropriate drugs or other treatments may be prescribed. Diagnostic tests may be needlessly repeated. Preventive measures may not be taken because each practitioner assumes someone else has provided them.

Different practitioners may have different opinions about a person's health care. For example, practitioners in a hospital may disagree with a person's primary care doctor about whether the person should go to a nursing home after being discharged. The person receiving care and family members may be overwhelmed and confused by differences of opinion among the various practitioners.

The health care system has many rules that affect continuity of care. The rules may be made by the government, insurance companies, or professional organizations for health care practitioners. For example, some insurance companies limit which hospital a person can go to. The person's doctor, if not on staff at that hospital, may be unable to provide care there.

Continuity of care may be disrupted when people do not have access to health care. Some older people do not have transportation to a doctor's office. Some do not have insurance and cannot afford to pay for health care themselves, so they may not see a doctor or specialist.

Who Provides Care?

For the best health care, a person may need to see several types of health care practitioners. Sometimes a group of health care practitioners work together to provide care for a person. This type of care is called interdisciplinary care.

Doctors: Older people may see many different kinds of doctors: family practice doctors, general internists, specialists in such areas as heart disorders (cardiologists) or cancer (oncologists), and surgeons.

Some doctors, called geriatricians, are trained specifically to care for older people. A geriatrician may be the person's primary care doctor or may be called in for a short time for consultation.

Nurses: Nurses check vital signs (blood pressure, pulse, and temperature), take samples of blood, give treatments, and teach people how to care for themselves. Nurses may ask about the person's health (for the medical history) and home situation. They may help coordinate care by communicating information to the different practitioners involved, the person, and family members.

Registered nurses (RNs) often provide most of a person's health care. Registered nurses supervise care provided by licensed practical nurses (LPNs) and nurses' aides. Registered nurses are taught to do a physical examination and check for changes that need to be evaluated by a doctor. They also can administer drugs to the person, as prescribed by a doctor. Licensed practical nurses may perform many functions but always under the supervision of a registered nurse.

Some nurses, called nurse practitioners, receive additional training in diagnosis and treatment. Thus, these nurses have more responsibilities than registered nurses. Some nurse practitioners, called geriatric nurse practitioners, are specially trained to care for older people.

Physician assistants: Physician assistants (PAs) perform some of the same functions as doctors and nurse practitioners but always with a doctor's supervision. Physician assistants ask about the person's health (for the medical history), perform physical examinations, order diagnostic tests, help doctors develop treatment plans, and assist in surgery. They do routine procedures, such as giving shots and stitching up wounds. Physician assistants also provide people with information about following their treatment plan and taking care of themselves (such as information about a healthy diet and exercise).

Physician assistants work in most places of care, including long-term care facilities. They may provide health care in a person's home. Some physician assistants specialize in treating older people.

Pharmacists: In addition to dispensing drugs, pharmacists evaluate prescriptions to make sure that appropriate drugs are being used. Pharmacists can check to make sure that older people are not taking drugs that pose special risks for them. Pharmacists also make sure that instructions are clear and include information about how much and how often a drug is to be used. They keep track of a person's prescriptions and refills. In this way, they can check for interactions between drugs.

Some pharmacists specialize in the care of older people. They are sometimes called consultant (senior care) pharmacists. They often work in nursing homes. They provide other practitioners with information about how to use drugs appropriately.

Dietitians: Dietitians assess how well nutritional needs are being met. When needs are not being met, they provide specific recommendations about which foods to choose and how to prepare foods.

Therapists: Different types of therapists may be needed, depending on the disorders and problems a person has. Physical therapists evaluate and treat people who have difficulty moving—for example, difficulty walking, changing positions (standing up, sitting down, or lying down), transferring from bed to chair, lifting, or bending. They work with people who have had problems such as a stroke, amputation of a limb, or hip surgery. Treatments may include exercise, heat, and ultrasound. Occupational therapists evaluate and treat people who have difficulty caring for themselves (for example, dressing or bathing), working, and doing other daily activities. Speech therapists help people who have difficulty using and understanding language.

Social workers: Social workers help coordinate discharges from hospitals and transfers between institutions. They may help people fill out insurance and other forms. They help people identify services that can be provided in the home and community and often help arrange for these services. They also evaluate how people are responding to the care and services obtained.

Social workers may bring family members together for discussions about important health care issues. Many social workers counsel people with anxiety, depression, or difficulty coping with a disorder or disability.

Most social workers are familiar with the special needs of older people. But some are specially trained to counsel older people and to determine whether they need supervision or additional help.

Nurses' aides: Nurses' aides care for people in hospitals, rehabilitation facilities, nursing homes, assisted living communities, or other medical facilities under the direction of nurses, doctors, and other medical staff members. They are sometimes trained to do some simple assessments of health. For example, an aide may measure temperature, pulse, and blood pressure. Nurses' aides may respond to signal lights or bells indicating that someone needs help. They bathe, dress, and undress people. They serve and collect food trays and feed people who need help eating.

Home health aides: Employed by home health care agencies, home health aides do many of the same tasks that nurses' aides do, but in the home. They help with daily activities, especially with dressing and grooming. These aides may prepare meals, help the person out of a wheelchair, or take the person for a walk. They sometimes help with light housework. They may also do some simple health assessments under the supervision of a registered nurse.

Medical ethicists: Medical ethicists help resolve conflicts over moral issues that come up during health care. For example, health care practitioners and family members may disagree about whether a treatment that appears to be ineffective should be stopped. Medical ethicists may be doctors, other health care practitioners, lawyers, or other people who have been specially trained in medical ethics. Some hospitals have a medical ethicist or a team of medical ethicists on staff.

Where Is Care Provided?

Health care practitioners may work in a variety of places.

Doctor's office: Most older people receive medical care as outpatients. That is, they see their doctor in an office, then they go home. A doctor's office is a suite of rooms where a doctor can take a person's medical history and perform a physical examination. The office may be in a medical office building, a clinic, a hospital, or elsewhere. Diagnostic tests, such as blood tests or x-rays, are often done in a doctor's office. If not, they may be done at a nearby clinic. Some doctors' offices offer certain treatments, such as physical therapy.

Hospitals: Hospitals provide the most comprehensive medical care, usually to people who are very sick. Older people may enter the hospital through the emergency department, or they may be scheduled for admission by a doctor.

A doctor (who may be the person's primary care doctor, a specialist, or a staff doctor at the hospital) is in charge of the person's care in the hospital. Sometimes several other doctors are involved. Nurses, who are available 24 hours a day, provide much of the care. A nurse is always available, but doctors may come and go at more irregular times.

Many other people may help provide care in a hospital. They include pharmacists, dietitians, physical and occupational therapists, social workers, medical technicians, nurses' aides, and volunteers.

How long a person stays in the hospital depends partly on how sick the person is, what the diagnosis is, and, if needed, what arrangements for continuing care can be made after discharge. The health care practitioners involved determine whether and what type of continuing care is needed. This care may be provided in a rehabilitation facility, in a long-term care facility, or in the person's home by a visiting nurse.

Rehabilitation facilities: After discharge from the hospital, people with a severe disability may need to continue their recovery in a rehabilitation facility. A facility may be located in a hospital or a nursing home. These facilities provide skilled nursing care and physical, occupational, and speech therapy.

When people are discharged to a rehabilitation facility, doctors predetermine how long their stay will be. For older people, the stay ranges from several weeks to a few months. Goals for progress are set, and progress is evaluated every day. Thus, the types and amount of therapy can be adjusted as needed. Some older people need to come to a rehabilitation facility periodically for therapy. Appointments can be scheduled for them.

Long-term care facilities: When older people need more help than can be provided at home and need it for an indefinite time, a long-term care facility may be appropriate. Older people or family members can choose among several living arrangements that provide different services and levels of health care.

Board-and-care facilities provide a room, meals, and some help with daily activities. Some facilities provide certain basic health care. Assisted living communities are similar. But they provide more health care, and most provide 24-hour supervision of the resident if needed. Some of these facilities have a registered nurse on site.

Nursing homes provide nursing care, including giving residents their drugs, in addition to help with daily activities. Nursing homes have at least one registered nurse on site at all times. They also employ licensed practical nurses and nurses' aides. Some homes provide physical and occupational therapy.

Life-care communities provide different levels of services and care, depending on need. Life-care communities guarantee that people, regardless of their health, are cared for within the community for the rest of their life.

Home health care: After discharge from the hospital, many older people who are well enough to go home need some health care services. Often, home health care agencies also provide some help with daily activities. These agencies employ registered nurses, therapists, home health aides, and social workers.

Some people need home health care for a short time after they leave the hospital. For example, a nurse may be needed to change wound dressings. Other people, especially those with a chronic disorder, need home health care for a longer time. People with a heart or lung disorder may need a nurse to visit regularly and check whether they are worsening or improving. The nurse can also adjust a drug dose if needed. Or a nurse may regularly visit people with diabetes to make sure they are following their treatment plan, to monitor drug use, and to adjust doses as needed. A physical therapist may be needed to help people regain strength and balance or recover from a stroke. A home health aide may be needed to help with shopping, preparing meals, going out in a wheelchair, taking a walk, or bathing. A social worker can assess whether people are receiving the services they need and recommend additional services if needed. A social worker may help arrange for rides to and from medical appointments.

Community services: In the United States, one source of support services and health care in the community is senior centers. In addition to social, recreational, and educational activities, some senior centers serve meals—an important service for people who cannot prepare their own. Often, senior centers are a place where family members who care for a person full-time can take the person and get a break from care (a service called respite care).

Many senior centers also provide some health care. For example, some senior centers have a nurse on duty at least a few days a week. The nurse can check blood pressure, make sure people are taking their drugs as instructed, and teach people about their disorders. The nurse also helps people with health problems determine whether they need to see a doctor. Sometimes the nurse contacts a person's doctor or family members. Some senior centers provide day care for people with mild to moderate dementia, and some provide physical and occupational therapy.

Other services available in the community include meal programs (such as Meals on Wheels), transportation services, help with daily activities, support groups, and respite care. Some religious communities provide many of these services. These services are usually inexpensive, and some are free.

Information about community services, including senior centers, can be obtained from the hospital (discharge planning or case management department), home health care agencies, local health departments, and religious communities. Senior centers can also be found by looking in a local telephone book or on the Internet.

Day hospitals: Day hospitals provide hospital care only during the day. They are usually located in a hospital. They enable people to have complex tests and treatments without having to check into an overnight (inpatient) hospital. Day hospitals are particularly useful for people who need rehabilitation over a period of time—for example, for people who have had a stroke or amputation of a leg. These hospitals also provide meals and transportation to and from medical appointments and therapy sessions.

The primary care doctor or a hospital may send a person to a day hospital. Day hospitals are usually used for a limited period of time (6 weeks to 6 months).

Hospice care: For people who have a progressive, incurable disorder, hospice care provides the treatments and services needed to control symptoms, ease pain, and help people and their family members prepare for the death. Hospice care may be provided in a person's home, in a nursing home, or in a hospice facility.

Hospice care usually involves a doctor, nurse, and social worker trained to care for dying people. Pharmacists, counselors, physical therapists, ethicists, and volunteers may also be involved. These practitioners are needed to make sure that all of the person's physical and psychologic needs are met as well as possible. Most people who receive hospice care do not have to transfer to a hospital before they die. Thus, they can die in a more comfortable, intimate environment, often with loved ones around them. Hospice care also involves helping family members prepare for the death and understand what to do when a person dies.

How to Improve Continuity

Improving continuity of care requires efforts by the health care system, by the people receiving care, and by their family members.

Health care system: Managed care organizations and some government health care plans coordinate all health care and thus contribute to continuity of care. Also, the health care system has developed several strategies to improve continuity of care. Examples are interdisciplinary care and geriatric case managers.

Interdisciplinary care is coordinated care provided by many types of practitioners, including doctors, nurses, pharmacists, dietitians, physical and occupational therapists, and social workers. These practitioners make a conscious, organized effort to communicate, cooperate, and agree with each other about a person's care. Interdisciplinary care aims to ensure that people move safely and easily from one place of care to another and from one health care practitioner to another. It also aims to ensure that the most qualified health care practitioner provides care for each problem and that care is not duplicated. Interdisciplinary care is not available everywhere.

Interdisciplinary care is important when treatment is complex or when it involves movement from one place of care to another. People who are most likely to benefit include those who are very frail, those who have many disorders, those who need to see several different types of health care practitioners, and those who experience side effects from drugs.

The practitioners who care for a particular person are called the interdisciplinary team. One practitioner, often the person's primary care doctor, coordinates care.

Sometimes the interdisciplinary team consists of health care practitioners who do not work together on a regular basis (an ad hoc team). In other situations, the team has the same team members—a group of practitioners that usually work together and that care for many people (an established team). Some nursing homes, hospitals, and hospice organizations have established teams.

Team members discuss plans for treatment and inform each other about changes in the person's health, changes in treatment, and results of examinations and tests. They make sure that the person's records are up-to-date and that the records accompany the person through the health care system. Such efforts help make changes in places of care or in health care practitioners smoother and less traumatic. Also, tests are less likely to be repeated unnecessarily, and mistakes or omissions in treatment are less likely.

The interdisciplinary team also includes the older person being cared for and family members or other caregivers. For effective interdisciplinary care, these people must actively participate in care and must communicate with the health care practitioners on the team.

Geriatric care managers are specialists who make sure that an older person receives all the help and care needed. Most geriatric care managers are social workers or nurses. They may be members of an interdisciplinary team. Geriatric care managers can make arrangements for the services needed and supervise these arrangements. For example, care managers may arrange for a home nurse to visit several times a day or for an aide to help with housecleaning and preparation of meals. They may locate a pharmacy that delivers drugs or arrange for transportation to and from the doctor's office. Geriatric care managers are relatively uncommon.

People receiving care: Actively participating in health care is crucial to improving continuity of care. Active participation begins with communication—giving and getting information. When older people have special health care needs, they or their family members should tell their health care practitioners. For example, some older people need help determining which health care costs are covered by Medicare, Medicaid, and other health care insurance.

When an interdisciplinary team or geriatric care manager is unavailable, people who are receiving care or their family members may need to become proactive in care. For example, they may need to ask one health care practitioner to call and talk with another to make sure treatment is appropriate. They need to establish a good relationship with at least one health care practitioner, usually the primary care doctor, to minimize the problems created by having several health care practitioners.

Active participation includes seeing a health care practitioner (usually the primary care doctor) regularly and following the instructions of health care practitioners. It means asking questions about a disorder, treatment, or other aspect of care. It includes learning how to prevent disorders and taking the appropriate steps to do so.

For people who have a disorder, active participation may involve self-monitoring. For example, people with high blood pressure can regularly monitor their blood pressure. People with diabetes can regularly check the level of sugar in their blood.

Keeping a copy of their medical record can help people participate in their health care. They can often obtain a copy from their doctor. Keeping a copy of the medical record is useful as a reference for information about disorders present, drugs being taken, treatments and tests done, and payments made. This information can also help people explain a problem to a health care practitioner. File boxes, binders, computer software, and Internet programs have been designed for this purpose.

When people go to a hospital or to a new health care practitioner, they should check with someone at the new location to make sure that their medical record has been received.

Buying all drugs (prescription and nonprescription) at one pharmacy or through one mail order service and getting to know a pharmacist there are also important. Older people can ask their pharmacist questions about the drugs they are taking. They can also ask for containers that are easy to open and labels that are easy to read.

See the sidebar Doctors by Any Other Name.

See the sidebar Who Are Geriatricians?

See the sidebar Adding to the Confusion: Other Specialists.