The Twilight Zone of Care Transition

by Louis on December 4, 2012

We will not get out of the twilight zone of care transition disorganization by muddling forward. Our current situation is depicted very well in this recent Washington Post Health Section article, Out of the Hospital and Into the Abyss. There must be a real effort to make the right tools available to the right people and pay for it. Our medical system is built on acute care in controlled environments.  Individual homes and lives are anything but acute and controlled. As we move to home rehab, home care AND avoiding readmissions we need a good system for transitions and continuing care.

The solution is not new services, products or technologies. It is not electronic health records or regulations and procedures, although all of those are important. The solution comes from integration of what we know and have available and making it useful. The solution connects data to our vast experience so complex situations are managed using resources very well and bringing humanity to the user experience.

Though most of my work is now about the big picture, I still work with individuals and families on strategies for remodeling their homes. It keeps me grounded in the reality of my client’s needs and lives.

Many of my calls are from the children of older folks looking for the next step, hopefully a final home solution for their parents. A good deal of my lead qualifying phone time  is about the actual health conditions and prognosis and the management capability and services available. Those elements make home modifications valuable. I don’t want my project to be successful but their goal of keeping their folks at home safely and indefinitely to be a failure.

I try to explain that regardless of the well prepared environment, continuous decisionmaking about care in the home is really hard. Health, and consequently care needs, are a moving target. You get things into place and take a breath only to have a health event change requiring adjustment to the care. This is a constant cycle. As a consumer you may almost constantly need to research your next provider. Even some you know from past use may be unavailable when you need them.

But these decisions are being made and these resources are being deployed constantly. With the data we can track from individuals in their homes and the vast data potentially available from medical records and the attention of thoughtful, experienced, caring, smart managers we can make the home care experience reasonable. The issues are complex but the idea here is simple. Someone who does it all the time does a better job than someone who does it once. The learning curve is eliminated, the stress of emotions and family dynamics is not a factor. These managers working from the coming data hub of high tech monitoring will be able to help families do much better jobs if we hire, train, support and empower them to do the job that needs to be done.

My family goes to a restaurant called  Uncle Julio’s when my son is in town. It is a bit noisy but we like the food and the service is great. We once asked a server how they got such good food and so many large and complex orders out so fast. The waiter told us they know from experience what to start cooking when people are seated. They use available experience data to anticipate needs so they can provide excellent service (and turn tables fast using their resources very efficiently)

I know health care at home is way more complex than restaurant orders but adopting data driven techniques from other industries is a smart move. We don’t have to invent the wheel…just adapt it for our purposes. We need to move quickly and with purpose to a better home care experience.

(A comment that came through twitter reminded me of a remarkably similar message from Eric Dishman with another dramatic personal story)


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