A physician’s view of care coordination in assisted living

How could, or how should, clinicians coordinate health care with assisted living facilities?

This is the question I was asked recently, by someone working with a senior living developer. Like many, the developer is hoping to leverage technology for better care coordination, care collaboration, and overall better aging-in-place. It’s an appealing idea, and we certainly need better coordination of care and information for seniors. But it’s a tough problem to solve, especially when people are residing in facilities. For instance, as I wrote last fall, I once found myself sending faxes to the PCP, the neurologist, the home healthcare agency, the private in-home caregiving agency, and to the facility itself. Plus I was emailing the patient’s family on the side. And we didn’t even have the hospital transition team involved; although that case was related to an elder doing poorly after hospitalization, by then the patient was well outside the 30 day window of interest to hospitals. How can clinicians and assisted living facilities coordinate on healthcare for older adults? Sorry, I can’t answer that question yet. However, what I can do is specify some of the issues that I find myself trying to coordinate with assisted living facilities.

Coordinating medications with an assisted living facility

This probably constitutes the bulk of how most clinicians interface with assisted living facilties. Here are some of the communication issues that often come up in my practice:

• Requesting a copy of the current medication list, so I can see what may have been prescribed by other providers. Ideally a current medication list would be viewed by clinicians every time a complaint is assessed, or medications are prescribed. In reality however, clinicians often end up relying on outdated/incomplete lists.

• Discontinuing medications. When patients are having medications dispensed by assisted living, it’s generally not enough to just tell the patient during a visit that they should stop something. Clinicians also need to send an order to the facility. It would, of course, be nice if there were an easy way to double check that a medication had been discontinued as requested (currently requires more phone calls and faxes).

• Ordering PRN (“as needed”) medications. Ordering is actually the easy part. The hard part is figuring out how patients will voice their need, and making sure that the facility is able to respond. Most of the time, patients and families tell me that they have difficulty getting PRN meds dispensed by facility staff. My guess is that this is because the facility staff are relatively busy, and perhaps haven’t had much training in managing PRN meds.

• Requesting a log of how much PRN medication was given. This information is essential if a clinician is to properly adjust a medication regimen and manage symptoms appropriately.
  • However, I’ve found is often absurdly difficult to get this data, and facility staff are usually puzzled when I ask for it. In fact, the staff at one facility recently told me that their policies forbade them from giving me a copy of the MAR (“medication administration record”), which is the part of the medication chart where staff document when they actually give medications. (Weirdly, the med tech offered to hand write the information for me; I pointed out that this was error-prone and insisted on talking to the nursing director about the policy.)

• Clarification/confirmation of current orders. Facilities often contact me if they have questions about a new medication order. Many facilities also fax a medication list regularly and ask the primary care doctor to confirm that the med list is correct. (Which can be challenging if the patient has been seeing lots of other doctors.)

Other issues I coordinate with assisted living facilities

Other than medications, I also sometimes try to coordinate regarding: