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Creating a 360-Degree View of The Continuum of Care

We used to think of healthcare as a linear journey, with a doctor tracking each patient as they moved from minor issues to chronic disease to community-based care to end of life. But 21st century healthcare operates more like a matrix, involving interactions with doctors, pharmacies, health plans, caregivers, therapists and nursing facilities – sometimes simultaneously.

You might think patient outcomes would be stronger than ever. But the abundance of available services can create gaps in care.

The issue is that healthcare complexity can eclipse the most relevant factors in the patient’s care story, particularly with chronic disease management. There’s often no central source of truth as the patient moves along the continuum of care. A patient may be treated for diabetes by one doctor, see a psychiatrist for anxiety, visit a physical therapist for a shoulder injury, and obtain medication for chronic back pain from another physician – with none of those providers aware of each other’s diagnoses or treatment plans.

Patients are getting lost in the gaps between their providers. Consider that:

Without collaboration and oversight, providers base their care plans on partial knowledge. PCPs may miss the opportunity to connect the symptomatic dots and catch a serious illness in time. Chronic diseases can grow worse, leading to costlier treatment.

The solution? Telemedicine, which acts as the connective glue to keep all providers and caregivers operating from a shared and current knowledge base. Patients can get faster care, avoid readmissions and the higher costs of more complex care.

Hazel’s Story

Hazel is 81. She lives alone and relies on her Social Security check and Medicare. She has a number of conditions, including chronic heart failure, type 2 diabetes mellitus, chronic kidney disease, osteoarthritis, and depression.

Lately, Hazel’s worsening arthritis has made it tough to visit her PCP. Instead, she calls him when she needs a prescription refill. Five months after her last visit, Hazel is hospitalized for kidney issues. After discharge, she doesn’t call her PCP to report the incident; when her son calls from another state, she doesn’t mention it to him either.

A month later, Hazel is readmitted to the hospital for kidney problems. This time they discharge her to a skilled nursing facility. She’s eventually sent home but the hospitalizations have accelerated her decline; walking, dressing, and showering have become more difficult for her. She depends on a neighbor to bring her microwaveable meals.

Alone and confined to her house, Hazel’s depression, hypertension and diabetes grow worse, as does her kidney disease. She needs a different level of care now, including dialysis and skilled home health services, but those need to be ordered by a doctor who’s seen her in a clinical encounter – and she’s too sick to visit her PCP.

Hazel’s condition grows worse until she calls an ambulance and is admitted to the hospital again. They discharge her to a nursing home. Her PCP doesn’t hear from her again.

The Value of Telemedicine Intervention

Better care coordination through telemedicine could have rewritten Hazel’s story in several ways:

  • Provider collaboration. Exchanging discharge care plans between hospitals, emergency room departments and PCPs is critical. The PCP could share more information about Hazel’s medical and pharmaceutical history while the hospital could share her discharge summary.
  • Disease management and monitoring. Hazel’s PCP could monitor her at home and identify emerging issues before they become serious and result in a readmission.
  • Home health care. A home health nurse could use telemedicine sessions to consult with the PCP or specialist, arrange for Meals on Wheels, and schedule transportation to PCP and dialysis visits.
  • Faster treatment. Telemedicine’s immediacy can speed up care interventions, whether it’s calling in prescriptions or treating a spike in blood pressure.

Telemedicine empowers consistent, thorough and timely care across acute and ambulatory settings. Providers can insert GlobalMed technology at the right touchpoints to track patients and help them get the right care before their conditions spiral and treatment costs begin to rise.

In today’s complex healthcare landscape, there’s only one way to stop patients from falling through care gaps. Evidence-based telemedicine can create a 360-degree view of the patient’s healthcare story and optimize care coordination, cost control and patient outcomes. It’s just another way telemedicine can benefit every player in healthcare.

Let GlobalMed guide you to the telemedicine solution that is right for you. Start by contacting us or scheduling a demo. A seasoned virtual care expert is on hand to help.

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