As if managing one disease wasn’t difficult enough, patients with multiple comorbid illnesses are often a considerable challenge for the healthcare industry. Still, there is little clinical research on the care of these complex populations, since clinical studies tend to focus on a single disease and often exclude patients with multiple diseases, and published guidelines usually don’t address the care of patients with comorbidities.
However, much like family doctors, your skilled nursing facility or your home health agency does not have the option of only treating patients in 1-disease silos. How do you develop an effective approach for keeping readmissions rates down and managing these patients with multiple illnesses, who make up more than 50% of family physicians’ caseloads?
The level of care coordination depends largely on the complexity of each patient’s needs, and patients with multiple illnesses are as complicated as it gets. With multiple chronic or acute health problems, social vulnerability and the number of providers and settings that a patient experiences also increases. It’s important for one care team to be explicitly and proactively coordinating care, especially when complex needs can overwhelm more informal coordinating functions. In order to keep patients healthy after they leave your SNF, you should make sure you do your part in the care coordination.
Having a comprehensive needs assessment for each patient is extremely helpful in outreach with managing complex populations. This assessment is more than just a standard medical history and complete physical examination. This assessment should include the patient’s need for:
After identifying all care needs and preferences of both the patient and the caregivers will make it easier for each aspect of care, such as your SNF, to formulate an individualized care plan. Having your SNF periodically update and participate in the needs assessment means upping the level of coordination of care, which can help your patient stay healthy outside of your domain.
In most cases, developing such a comprehensive assessment requires teamwork between you and the patient’s primary care practice team, as well as social workers, therapists, and caregivers, since not everyone will have the skills and knowledge to do so.
Having this will allow your SNF to create a care package unique to each patient’s needs.
Complex populations often have conditions and needs that require a multitude of health and long-term services and supports, so care coordination requires attention to a broader set of services than is typically offered by most healthcare facilities.
The patient might need assistive technology and durable medical equipment like canes or motorized wheelchairs when they leave your SNF. They might need hands-on help in the form of physical therapy, personal care assistance, transportation inaccessible vans to get to medical appointments or shop for groceries, and home-delivered meals. They’ll often need help accessing public benefit programs, such as Medicaid or food stamps.
This is a daunting challenge, since often, care coordination is already difficult within the traditional medical care infrastructure. This step, however, is critical in helping complex populations stay independent and healthy. One way to do this could be to have other social services integrate with your SNF to provide better coordination or to refer them to a proper home health agency.
But by setting up and helping patients or their families navigate the public and private benefits available to them, your SNF could have better results.
Perhaps the most important in managing patients with comorbidities is the regular monitoring of the patient’s health status, needs, and services, and through frequent communication and the free exchange of information. This could come in multiple forms: in person, by phone, or in writing, or by using other electronic tools, like reminders or software like Cortex.
Regular communication should be had between healthcare professionals and patients and their families. This helps patients and their families to fully understand their care plan, responsibilities, and available help. Additionally, make sure to communicate well with the patient’s home health agency, if your patient’s care is transferred to one.
Having this open communication and monitoring helps support patients in the challenges of adhering to therapy schedules and other elements of self-care that might be difficult to stay accountable for otherwise.
The aforementioned communication and integration was once a barrier to making this work. But luckily, today, software like Cortex exist. Your SNF doesn't want your past patients to readmit, so to help your patient recover at home, utilizing the right software can streamline the whole process. For example, Cortex’s follow-up call program helps your SNF understand a patient’s post-acute performances, with real-time feedback by using the Cortex Nurse Marketplace to make follow-up calls to patients recovering at home. You could also survey patients via tablet questionnaires so that your data could then be compared against national percentile rankings.
It’s effective software and careful solutions like Cortex that has been proven to prevent readmissions and help measure patient recovery post-discharge.
Conclusion
Taking on comorbid patients can be daunting, especially with the complexity involved and the lack of guidance. But, by implementing these tips we’ve gathered from healthcare and medical research across the internet, we can all take the healthcare industry a step in the right direction.