Care Coordination: Keeping Everyone on the Same Page


Published: 03/15/2012

by Michelle Seitzer


Caring for a senior loved one, particularly during a medical emergency, can quickly become like the childhood game of “telephone:” as the information is passed down the line from doctor to nurse to senior to caregiver(s) to hospital discharge planner to nursing home admissions director and back up through the line, the details get fuzzy, things get lost in translation, and mixed messages multiply.


Keeping everyone on the same page, especially as the individual’s health status can change dramatically and often in a 24-hour period, requires a tremendous amount of coordination and clear communication.


There are two levels of coordination though -- the family level and the care professionals level.


At the family level, it’s often best to designate a “point person” (someone to speak with/listen to the doctors, nurses, discharge planners, social workers, and any others involved) and another as the primary “courier” (the person who receives information from the point person and passes it on to the rest of the family).


However organized the family may be in receiving and delivering messages from the healthcare providers, they have little to no control over how the various providers communicate among themselves.


In Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, the U.S. Department of Health & Human Services defines care coordination as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”


Using a term like “marshalling” clearly implies what a cumbersome process these multiple levels of involvement, conversation and decision-making becomes. 


Still other complications arise when providers disagree amongst themselves about next steps: the hospital discharge planner may want to transfer the patient to a local nursing home or rehab facility, but the doctor may think another day in the hospital to run more tests is best. Bring the family members into the equation and it is likely the discord will continue. All of this back and forth can have a negative effect on the patient at the center of it all, the person who needs care.


Another unfortunate reality further complicating this entire process: time and money. Where the individual is currently placed at the time of crisis (hospital, nursing home, etc.) and who is paying the bill can all play into how quickly a care decision needs to happen.


Thus, family members are forced to make difficult decisions in stressful circumstances, and often with limited or unclear information. Unfortunately, there is no way to know when a medical emergency or care crisis may arise. There is no way to know how organized your loved one’s care providers will be or how clearly they will communicate with you and with each other.


The best way to stay ahead of the care coordination curve? Ask all the important questions now: what care setting does your loved one prefer, what are her end-of-life wishes, does he want extraordinary measures to be taken, what options can your loved one afford, and so on. The ER waiting room at midnight is not the ideal time or place to think these difficult issues through.