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Care Management Insight: 4 Pillars of Transitional Care

Home sweet home. Most of us want to stay home when we are sick and even more as we get older and need care.

Unless there are extenuating circumstances, we certainly want Mom and Dad to stay home and be well cared for instead of seeing them have to go into a nursing home, assisted living or board and care facility.  However, as our loved one’s age most of them have some combination of chronic illnesses that present constant challenges. Sometimes they need some help in managing their health issues.

The things that most often take elders out of their homes and to the nearest emergency rooms can sometimes be avoided by doing some simple things on a regular basis. Dr. Eric Coleman refers to these things as the “four pillars” of transitional care. Truth be told they are really just common practices for professional geriatric care providers who understand how to use the basic tools for good chronic disease management at home.

Here is a shortlist and explanation of how important each one is and how a family member can get these in place.

  1. Physician Appointment Calendar:

Make sure that the appointments your loved one has with their doctors are made in a timely fashion and are actually attended with full information transferred to all caregivers, whether they are family members or agency caregivers. If you or a family member is the acting power of attorney for health care and you are not able to attend doctor’s visits, you can ask for the visit notes to be faxed to you after each appointment.

  1. Communication with all Medical Providers:

Two-way communication with your loved one’s physicians is critical. Coordination of care between multiple medical providers is an important key to managing care successfully at home. Each doctor needs to be kept current on what medications and treatments the other doctors have initiated.  Reactions to new medications and all changes in condition need to be reported to appropriate physicians on a regular and timely basis.

  1. Medication List:

Keep a medication list that documents all medications, when they were started and stopped and what doses and times they were given. Make several copies so that all routine providers, as well as emergency medical providers, have access to a current medication list. Include allergies to medications and any specific reactions to each medication on the list.

  1. Monitoring Vital Signs:

Keep a record of vital signs taken as often as needed. Vital signs include temperature, heart rate or pulse, respirations and blood pressure.

A digital blood pressure cuff will measure both blood pressure and heart rate. This data is easy to collect and an extremely important window into the real-time medical status of your loved one. Weights are also an important metric for those with hypertension and cardiac disease. Weights should be taken daily for anyone with congestive heart failure (CHF). Weight gain of over five pounds in one week should be reported to the physician as it can be connected to fluid retention, which will directly impact respiratory status. For those taking hypertension medications, blood pressure should be taken before blood pressure medications are given to make sure that the medication doesn’t drop blood pressure too low.

Many falls and adverse events are caused by over medication. Ask your physician for parameters to use to know when to hold these medications. The same is true for cardiac medications that can drop heart rates. Blood sugars should be checked with a glucometer per your physician’s order and documented. Again, ask your physician for medication parameters. For those with respiratory problems, a pulse oximeter will measure the oxygen level in blood by using a small device that fits on the end of a finger. You will know by monitoring the oxygen saturation digitally when to use oxygen. All of the monitoring tools mentioned here are available for purchase from your local pharmacy.

All of these measures presuppose several things: that the elder is able to participate in some degree of self-care, or if not that there is someone at home or coming into the home to manage and monitor things. Clearly, this is not always the case but when there is a care system in place, the “four pillars” are essential components to delivering the best home care.

If you need help managing the care of your loved one and implementing any of these steps, we are here for support.  Give Grace Care Management a call at (760) 789-9177 for a free consultation.

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