Care Coordination in Rehabilitation and Homecare

I have been able to closely observe the challenges that my clients in outpatient physical therapy clinics deal with daily as they navigate the intricacies of our health care system and attempt to provide the excellent care their patients deserve. The real work in physical therapy—analyzing a patient’s problem, finding the right solution and helping them reach their goals—is incredibly rewarding. The interactions with patients can range from challenging to absolutely inspirational. The actual work is a joy, and I cannot imagine a better profession. But, that joy can be sucked out of you by the drudgery of the side work in physical therapy: countless reports, ineffective and time-consuming communications, insurance authorizations and everything else attendant to the nightmarish government and insurance bureaucracy. The net result is that much of the important work needed to actually coordinate a patient’s care across health care settings never gets done. Sure, faxes fly back and forth between physicians, hospitals, pharmacies, physical therapists, case managers and payers, but there is very little actual assurance that the provider on the other end received any useful information. It would be great to just email or text another provider, but HIPAA considerations make electronically transmitting protected health information difficult.

Communication Difficulties

One of the root causes of our inter-provider communications problem is the hodge-podge of electronic medical record (EMR) systems that do not talk with one another. Centralized health information exchanges (HIEs) have been touted over the years with the promise of centralizing a patient’s health care record so all providers can access needed information at the point of care. But, the promise of HIE systems has not been realized and still seems a long way off. Most HIEs have failed, simply because they were not financially viable. The patient is still usually caught in the middle and forced to provide the same information over and over again about their medical history, allergies and current treatment. Of course, providers are relying on the patient to provide information that they may not be able to convey accurately themselves. One of the promises of value-based care strategies and meaningful use incentives was that these barriers to effective communication would be torn down, resulting in better coordination of care across these health care silos. For example, Medicare’s Comprehensive Care for Joint Replacement program provides hospitals with incentives to coordinate post-acute care with goals of reducing complications and readmissions and improving care quality. Until something makes centralized HIEs a reality, a short-term solution may be patient-mediated exchanges. In a patient-mediated exchange, the patient would set up and have access to his or own secure central health care information repository, and simply ask providers to securely upload their medical records to that repository. The patient then has control over sharing that information with other providers, simplifying HIPPA compliance. The problem with a patient-mediated exchange is that it requires patients to be active participants in their own health care and to have at least some familiarity with the internet. Let’s explore how this might work with a fictitious case study.

Case Study

George is an 82-year-old male with a number of chronic health conditions, including macular degeneration and mild dementia, making it difficult for him to fill out forms when visiting physicians and other providers. He was recently discharged to his home following a total knee replacement. He has been referred to home health for nursing care and physical therapy. George’s daughter, Debbie, recognized long ago that George’s internal medicine physician was not getting timely reports from other providers, so she set up a patient-mediated medical record account for her father, and printed off some simple instructions on a wallet size card that her father now carries with him. The card contains:

• Instructions to providers on how to access George's information;
• Instructions on how to upload new information to the account;
• Debbie's contact information.

It also instructs providers that George is competent enough to sign any necessary documents allowing access to the health account if providers are unsure about HIPPA violations. Even though George did not really understand how the personal health care record worked, he did understand that it included information that was vital to his care, and it was much easier for him to hand someone the card than it was to try to fill out forms himself or relay his own medical history. Following discharge from the hospital for his surgery, all of the records of the hospitalization were uploaded to George’s account so his home health nurse and physical therapist could review them. They had a complete account of George’s medications, allergies and discharge summary. As part of the Comprehensive Care for Joint Replacement program, the physical therapist is able to help George fill out a patient-reported outcomes survey and keep a record of the survey results. The results of the survey are automatically transmitted to an outcomes system from the home health system’s EMR so the outcomes results for all of the patients with total hip and knee joint replacements can be tabulated to fulfill the hospital system reporting requirements. The technology necessary to engage patients and families in managing their own care is already here. Realizing the promise of patient-mediated health care exchanges will primarily rely on educating patients and providers alike about the benefits and possibilities.