With chronic ailments on the rise, hospitals are ill-suited to serve.
Over the last century, cause of death in elderly populations has shifted away from acute illnesses, such as pneumonia and tuberculosis, to more chronic and degenerative long-term ailments. This means the elderly are living longer (as evidenced by growing elderly populations across the globe).
Given the incredible advancements in modern medicine, this comes as little surprise.
Despite these advancements, we still use the same treatment model we used hundreds of years ago – the hospital. Unfortunately, the traditional hospital system (where patients are taken in for one-time treatment and released) is now ill-suited for treating the majority of the elderly population.
The hospital setting is perfect for treatment of acute diseases. Patients check in, receives a diagnosis, and some fort of treatment is prescribed. But, the shift toward the need for treating longer-term ailments also means a shift toward the need for longer-term care.
Treating the hospital system like a long-term care facility is highly inefficient, both for patients and the hospital workers themselves. It is also prohibitively expensive. Unfortunately, that is not stopping a large part of the population from treating hospitals and emergency rooms as their primary care option. In fact, more than 95% of American health care costs are attributed to chronic diseases, in no small part because patients often don't have any other choice.
The result is a vicious cycle of reactive care, where a patient puts off going to the doctor until the ailment becomes too much to deal with, at which point they spend more money treating its most severe symptoms, all within an environment where risk of infection is far higher than anywhere else.
Instead, the elderly and those that care for them should be looking to shift from a hospital-centered model to a patient-centered model; one that includes alternative forms of care outside of the hospital setting, such as in-home care and preventive care.
Personalized care teams can spot worrying trends and symptoms far before the need for hospitalization, leaving the patient with more options for treatment. In turn, this frees up hospital staff to focus
on what they do best: treat emergencies and acute illnesses.
Finding a personalized or in-home care team has historically been a challenge, but many insurers are realizing that preventive care is not only less expensive for the patient, it is less expensive in the long term for their own policies.
See how Keystone Health can help.
The time between being discharged from a hospital and settling into a home care routine can be tricky and confusing for many patients. Moving away from round-the-clock care by teams of highly trained medical professionals to a home or assisted living setting is oftentimes shocking and confusing, particularly for patients with degenerative conditions such as dementia, diabetes, etc., and treatment can suffer as a result.
This is where Transitional Care Management (TCM) becomes such an important part of health care. TCM is the practice of easing the transition from the hospital to the home. TCM is typically designed for a 30-day period, and could include any combination of interactive contact, face-to-face visits with medical staff, phone calls, or other types of monitoring. Through this sustained communication and contact, patients are ensured quality of care as they settle in to their homes.
First contact by a medical professional in charge of the TCM process should be made within two business days of the patient being discharged from the hospital. Depending on the condition, TCM may be provided by a wide range of medical professionals, including CNAs, nurse practitioners, and physicians.
The remainder of the 30-day TCM period is often spent connecting with healthcare professionals to ensure continuity of care, getting help with medication regimens, and receiving education and support for treatment and pain management. Face-to-face visits may also be completed, generally within one to two weeks of the patient being discharged from the hospital or clinic.
Patients must be released from a qualifying service setting, such as a skilled nursing facility, inpatient acute care hospital, partial hospitalization, hospital outpatient observation, or inpatient psychiatric hospital in order to qualify.
The primary goal of TCM is to ensure that there are no gaps in the patient's care. As such, the TCM provider will assist with medical decision making during the transition period. The level of medical decision making required to meet the individual patient's needs will be determined by factors such as the number of possible diagnoses or management options, the amount or complexity of medical records and diagnostic tests, and the risk of significant complications.
Transitional care management is an important piece of the puzzle for monitoring and managing chronic conditions. It helps ensure that the patient's needs are being met during the transition from inpatient care to the patient's community setting, reducing the risk for relapse and readmission.
As dementia progresses, one's ability to communicate begins to decline. It is up to you, as a caregiver, to learn how to communicate effectively throughout these different stages. Doing so is important for mental well-being and fortitude.
(According to the World Health Organization (WHO), more than 47 million people are living with dementia, and that number is expected to triple by 2050.)
Early on and into the middle stages of dementia, sufferers still have some degree of awareness and are therefore wise to the fact their mental ability is deteriorating. Understandably, this can be a very scary and difficult realization, making it all the more important for you, the caregiver, to be patient and understanding during moments when your loved one is struggling to communicate.
Tips for Communicating Effectively:
Providing in-home care for Alzheimer's and dementia is a challenge and can quickly become overwhelming, but effective communication techniques can go a long way. For additional tips on caring for loved ones with Alzheimer's and dementia, see this primer.
Idaho's leading house call provider since 2013, Keystone Health provides in-home health care and geriatric medicine for home-bound adults with chronic medical conditions: