2.1.4 Assuring availability of the care plan across settings, providers, and time


The discussion above has made clear that the care plan, once agreed upon, should guide all services toward achieving the elderly person’s priority goals. To accomplish that, the care plan itself needs to be available to key team members, including the elderly person and caregivers. This has proven to be quite difficult as frail elders move around from home to hospital and nursing home, or change home care attendants or physicians. One workable solution has been to give the elderly person or family caregiver a copy of the care plan to keep and take along. In just a few situations, such as PACE and hospice, all members of the care team are working in the same environment and can even stay involved when the elderly person is admitted to the hospital, so communication among the team is easy and is valued. But in the usual situation, the various parts of the service delivery system do not share records, do not even have compatible records, and often include both provider organizations that are covered by privacy laws and provider organizations that are not. These issues incur substantial problems that only will be solved by the eventual interoperability of records and inclusion of organizations providing services like housing, transportation, and personal care. In the meantime, creative interim solutions suitable for each setting will have to suffice.

Piloting of interoperable health care records for frail elders in the community is underway. The Office of the National Coordinator for Health Information Technology has coordinated a confederation of volunteer groups working on these problems. The scope of the care plans they are working with is still very short-term and tied to transitions in setting of care, but they have standardized the elements of a record format likely to support more comprehensive and longitudinal care plans. For example, Maryland’s health information exchange (CRISP, at crisphealth.org) is developing a way to incorporate a care profile into the notification process for a person who uses a hospital. This standardized care profile includes recent utilization, medications and other treatments, diagnoses, demographic data, advance directives, and contact information. In addition, if a documented care plan exists, it can be available through a link in the care profile.

The nation’s hospitals and physician offices have been able to obtain substantial financial support for adopting electronic records, so long as they meet certain standards.[52] Unfortunately for frail elders, providers of long-term services and supports are not included in this program, and the requirements thus far only include information adequate to facilitate safe transfers from one setting to another. Communities that aim to adopt a MediCaring model will need to assess their community’s capacity for interoperable records and devise a strategy that enables reasonable continuity and comprehensiveness as well as 24/7/365 access.

[52] (Office of the National Coordinator for Health Information Technology, Meaningful Use Stage 3, 80 FR 62648 2015)

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