In today’s post-pandemic healthcare landscape, the need to ensure the seamless delivery of quality patient care across multiple medical disciplines has never been greater. All too often, the most vulnerable among us are balancing the care of multiple chronic conditions while trying to navigate a complex and fragmented system of healthcare services. Your typical senior patient may be receiving care from a primary care physician (PCP), one or more medical specialists, or home health or nursing services, among others. The reality is, the traditional fee-for-services model of healthcare delivery has created silos within the system, resulting in poor continuity of care and, ultimately, suboptimal patient outcomes.
Enter the continuity of care model, a value-based healthcare delivery system that stresses coordinated care among all members of a patient’s healthcare team for a lifetime. This type of care management puts people first and has been shown to improve patient outcomes, decrease hospital readmissions and ER visits, and save on overall healthcare costs. In order to truly provide this type of care, doctors and nursing staff must be able to coordinate care across the continuum—from inpatient to outpatient settings, and across different provider specialties. At 1 True Health, continuity of care is at the heart of all we do. Our team of compassionate and experienced healthcare professionals work together to provide each patient with the coordinated services they need for comprehensive care and improved quality of life. This also helps ease the burden on already stressed nurses and other staff members. This article will discuss the aspects of continuity of care and how 1 True Health helps healthcare providers deliver top-tier care to seniors while making their own life-saving work easier and more effective.
Coordinated continuity of care is how you deliver better care, improve outcomes, and reduce expenses.
The Multi-Dimensional Model
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The Mutually Beneficial Model
There are many benefits to continuity of care, both for people we serve and our healthcare system as a whole. With its primary focus on prevention and proactive management, continuity of care has been shown to improve patient outcomes while also reducing healthcare costs. Continuity of care is indeed a more efficient and effective way to deliver healthcare, and it is quickly becoming the new standard in chronic care management. So how can this model benefit both your patients and your practice?
Your patients will have:
- 24/7 access to care (nurse line)
- A dedicated Care Navigator and care team
- Improved coordination among PCPs and specialists
- Reduced hospitalizations, readmissions, and emergency room visits
- Improved health outcomes
- Greater engagement and satisfaction with their healthcare plan
Your practice will have:
- Decreased overall healthcare costs
- Improved chronic disease management
- Lower costs associated with chronic care management
- Care plans tailored to the unique needs of your patient population
- Stronger rapport and relationships with the people you serve and their family members
- Health equity among your patient population
1 True Health is committed to providing continuity of care that meets the needs of both the people we serve and our healthcare system. We believe that continuity of care is a win-win for everyone involved. When you outsource care continuity to 1 True Health, you can be confident that the people you serve will receive the high-quality, coordinated care they need to stay healthy and happy, and reduce the risk of ending up in a hospital emergency room.
Threats to Continuity of Care
Despite its many benefits, continuity of care is often interrupted. These interruptions, also known as care fragmentation, can have a negative impact on both patients and healthcare providers. When fragmentation occurs, it can lead to duplication of services, conflicting treatment plans, and a lack of coordination among doctors and nursing staff. This can be especially dangerous for older people who have multiple chronic conditions. There are many potential causes of care fragmentation, but some of the most common include the following:
The primary care physician is often the cornerstone of care continuity. They are typically the first points of contact for people seeking basic medical attention and act as coordinators for the rest of the healthcare team. However, a shortage of primary care physicians in the United States has made left many PCPs feeling overwhelmed and unable to provide continuity of care on their own. [AAMC Report Reinforces Mounting Physician Shortage | AAMC] It’s also left many people without a regular source of care. For this reason, it’s become increasingly important to find ways to supplement primary care with other care services.
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1 True Health: Offering Interventions for Care Continuity
Continuity of Care in Action
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Chronic Care Management and Continuity of Care
COPD can be unpredictable, so it’s important that your COPD patients have a continuity of care plan in place. People who live with COPD often experience exacerbations or “flare-ups,” which can be caused by any number of things, including weather changes, infections, and air pollution. These exacerbations can be serious, and often lead to hospitalization. COPD is a tough condition to manage, and patients with the disease often, as demonstrated in this article, have high rates of hospital readmission as well as non-compliance.[Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions - PMC (nih.gov)] To make matters worse, healthcare organizations are often penalized under strict CMS regulations regarding readmissions within 30 days.
Continuity of care plans for these patients should include (at a minimum) regular check-ins with their healthcare team, education on disease management and flare-ups, and a clear understanding of what to do in case of an emergency. Remote patient monitoring (RPM) can also be a helpful tool for COPD patients, as it allows them to send data such as pulse oximetry on their symptoms and health status to their care team on a regular basis. This information can help the care team to catch exacerbations early and prevent them from becoming serious.
The goal of continuity of care for those living with COPD is to help them manage their disease, avoid exacerbations and hospitalizations, and maintain their quality of life. Our team works with patients and family members to develop a care plan that fits each individual’s needs. We also provide education on COPD, its management and typical medications, and what to do in case of a flare-up or exacerbation.
Whether diabetic patients are insulin-dependent or not, continuity of care is essential to disease management. People with diabetes are at increased risk for several medical complications such as heart disease, stroke, kidney disease, and blindness. High quality medical care, such as is associated with continuity of care practices, can help to prevent or delay the onset of these complications by providing regular check-ins, education on self-care and disease management, and early detection and treatment of problems.
Continuity of care plans for people living with diabetes revolve around maintaining acceptable glycemic levels. For those who are insulin-dependent, this often means frequent blood sugar testing and regular adjustments to insulin doses. For all diabetics, diet and exercise are important self-care activities that can help to control blood sugar levels. Education on these and other related topics is an essential part of continuity of care for people living with diabetes.
1 True Health Care Navigators work with diabetic patients to develop continuity of care plans that fit their individual needs. We provide education on medications as well as disease self-management and work with them to ensure they have all of the resources they need to incentivize healthy choices and promote glycemic control.
People living with CHF or congestive heart failure often have a difficult time managing their condition due to the progressive nature of the disease. As the heart weakens, it becomes less able to pump blood efficiently which can lead to a build-up of fluid in the lungs and other issues. This can cause shortness of breath, fatigue, and other symptoms that make it hard to live a normal life. The disease is often marked by periods of stability followed by sudden exacerbations or worsening of symptoms, which can be very dangerous. Continuity of care is essential for people living with CHF. Depending on the individual needs of the patient, care interventions for those with CHF may include regular check-ins with a care team, remote monitoring of symptoms (via wearable devices or apps), education on medications, disease self-management, and guidance on what to do in case of an exacerbation.
At 1 True Health, we work with patients and their family members to find solutions that fit their individual needs. Our care navigators provide educational resources on CHF and work with patients to ensure that they have the tools they must have to help maintain health and decrease hospital readmissions.
High blood pressure, or hypertension, is commonly known as the silent killer, and for good reason. People with hypertension often have no symptoms and may not even know they have the condition. Left untreated, hypertension can lead to heart disease, stroke, and kidney failure among other serious medical complications. Hypertensive patients, even those with no symptoms, are at risk for these complications and need continuity of care to prevent or delay their onset.
Continuity of care practices for these clients may include regular check-ins with a provider or care team, remote monitoring and recording of blood pressure trends and levels, education on medications as well as disease self-management, and guidance on what to do if blood pressure levels become too high.
The compassionate team of Care Navigators at 1 True Health work with hypertensive patients to build a sense of trust and rapport. We develop continuity of care plans that provide education on health maintenance along with medications and disease management. We work with the people we serve and their family members to help them get the resources they need to stay healthy and out of the emergency room.
Perhaps one of the most frightening aspects of getting older lies in the potential for cognitive decline. As we age, it becomes more likely that we will experience some form of cognitive decline, whether it be memory loss, difficulty concentrating, or problems with executive function. These changes can make it hard to live independently and manage our daily activities. They can also make it difficult for family members who don’t have enough experience with cognitive decline to understand and support their loved ones.
Developing a continuity of care plan for people experiencing cognitive decline can help bridge the gap for both patients and their families. Such plans may include regular check-ins with a care team, education and support for family caregivers, and guidance on how to cope with the changes that come with cognitive decline.
At 1 True Health, we understand the challenges that come with cognitive decline, and we are particularly adept at developing care interventions that meet the needs of both patients and family nurse/caregivers. Our navigators understand the importance of education and support, and they work consistently with patients and families to ensure that they have all the resources they need to cope with cognitive decline.
Looking to help your patients manage their chronic conditions more effectively? Contact us today and let our care navigators help you help your patients live their best lives!
1 True Health is dedicated to helping our clients provide the best value-based care for their patients. Contact us today to learn more about how we can help you improve continuity of care at your practice.
Why 1 True Health?
Who We Help and How
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Ready to Outsource Your Continuity of Care Process?
If you’ve been on the fence about outsourcing your continuity of care plans, now is the time to take the plunge. 1 True Health stands ready to help you improve continuity of care practices for the people you serve in clinical practices and senior living communities. There has never been a better time for your patients or senior living residents to have access to coordinated care services. Help prepare at-risk populations for upcoming health concerns, manage conditions more proactively, and identify potential care gaps before they happen and turn into costly hospitalizations. And while you’re at it, improve operations and reduce nurse burnout rates by taking advantage of our care management services. We can help you manage your patients’ care more effectively and efficiently so you can focus on providing the best possible care. If you’re ready to get started, we are, too. Contact us today to learn more about how we can help.