The Trouble with Home Health Care & Care Coordination

Leslie Kernisan new headshotHome health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially home bound due to frailty or illness.

But it often feels surprisingly hard to synergize with home health care.

The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)

Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.

And things get even more complicated when it’s a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.

Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).

I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And on the other hand, she had a fungal rash in her groin, under her incontinence brief.

I prescribed an antifungal cream to be used twice a day for two weeks.

Now it’s been three weeks, and the pharmacy is requesting a refill.

Well…what’s going on with that rash?

What I want to do is send an email to everyone who is involved and might know something.

That means an email that would include:

  • The patient’s son, who visits weekly. He’s not a medical expert but he has the most at stake in ensuring that things are checked up on, plus I had him take a look at the rash when I visited.
  • The home health agency RN
  • The paid home aides; I strongly urged them to start keeping a log of the patient’s skin condition at my last visit. (Is that part of their job? Should it be? Who knows.)
  • The facility RN, who is supposed to keep tabs on things when residents have active health issues, and who helped recruit home health care to the situation
  • The pharmacy, to tell them why I’m not renewing the medication right at this moment.
I would also like to loop in the primary care doc, but her patient hasn’t been able to come in to see her for a while, so she is the least actively involved member of the care team at this particular moment.
The great thing about email is that you can address it to several people, and when someone replies everyone else can see the response.
The bad thing about email is that it’s not secure. It is really not an option.
So what am I left with? The doctor’s old standbys: the phone and the fax.
Oh sure, someone out there has developed care coordination software that includes secure messaging.
But if we are not already all subscribed to it (which seems unlikely, unless you consider people working in an integrated care system), it’s really not usable unless someone wants to go through the hassle of getting each individual player subscribed.

So fax it is. Fortunately my EMR allows me to associate a given patient with a variety of other providers (and their fax numbers). It’s still a minor pain to fax a message to several different people, but it’s faster than calling them all.

BTW, I do occasionally call home health care agencies and ask to talk to the nurse. They are usually so surprised to hear from me…because most doctors never try to coordinate much.

What came first: the chicken or the egg?

What will come first: the communication framework or the desire to truly coordinate care?

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She blogs at GeriTech.

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Christine CaldwellMike EidsauneLinh Nguyen, MD, MMMLeslie Kernisan, MD MPHGranpappy Yokum Recent comment authors
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Christine Caldwell
Christine Caldwell

There is a Personal Health Record available today that seems to answer all of the concerns. The beauty of it is, now that Medicare is reimbursing for Chronic Care Management (CCM), the PHR is free to the patient, their family members, physicians and all other providers (including home health staff). It is called CareSync. CareSync specialists will request medical records from any number of doctors and providers, consolidate them into an easy-to-read Timeline and Care Plan and make it available to everyone listed above. Medication lists are kept up to date automatically and reminders sent as to when to take… Read more »

Mike Eidsaune

Leslie, As an entrepreneur trying to solve this problem, I definitely applaud your effort and nonacceptance of the status quo. In your case, I can see the frustration and sympathize with you. There are a lot of reasons the solution hasn’t been created already, the main one being HIPAA. In the case you described, everyone involved in that communication would have to be given several levels of clearance to join in the conversation, making the end product very cumbersome. However, our belief is that if communication goes one way (from family member to care professional), those restrictions come off. For… Read more »

Linh Nguyen, MD, MMM

I have spent 9 years Lestlie to go after a vision and mission, Patient Value First. We are now 100+ to solve what you are talking about. Finished cookie cutter and will test California, a heavy HMO penetration, to see if i am still successful there. If yes, i believe i have the answer to the “Challenges at Home”. If you are in Phoenix, AZ, i welcome you to visit us OK. Best regard, LCN.

Granpappy Yokum
Granpappy Yokum

“Well, I have never said that care coordination will make things cheaper/easier…”

Great point (that I don’t think many of the thought leaders realize).

Granpappy Yokum
Granpappy Yokum

An e-mail to seven people to discuss the issue of refilling a topical antifungal for one patient? The system will rapidly screech to a halt with this degree of “care coordination.”

Leslie Kernisan, MD MPH

Well, I have never said that care coordination will make things cheaper/easier…certainly not in the short run although I think you can improve outcomes in the long run, and you might also reduce confusion for families, which is not an outcome that will show up on spreadsheets but is still worthwhile. BTW initially when I saw the patient, the paid in-home caregivers had been applying anti-fungal cream to the pressure sore. They are taking on a lot of quasi-medical work, with relatively little training. For a situation like this I don’t think you need seven people around a table, but… Read more »

Scott Baker

This is definitely a big issue. I work for a startup that’s focusing on solving this problem, and it helps that we let non-subscribers be invited to coordinate patient care for free. Still, people want to communicate with doctors the way they communicate with everybody else—email and online messaging—but until people commit to a secure, easy way to do that, we’re stuck with archaic methods. Sometimes, the communication just doesn’t happen at all because nobody wants to deal with the phone or fax.


@LESLIE KERNISAN, Home health care is good but there are lot of coordination problem associated with it. I think you have described all the issues related to the home health care.

Hans Duvefelt, MD

I am fortunate, and stubborn, enough to have a good enough working relationship with all the home health nurses in our area to get a phone call that interrupts me whenever they have something new to report as well as when they make their first “intake visit”.
Anything else isn’t just inefficient, but potentially unsafe.

Leslie Kernisan, MD MPH

That is great that the home health nurses feel they can call you.

A phone call is a good start, but when I ask the nurse to send me what she just told me by fax (so I can put a written document in the record), most of the time nothing comes through.

I like phone to exchange ideas and have a chance to ask questions, but important info should be put in writing.