Everything is fragmented
Hospitalists speak to elderly people, but not their caregivers. The patient forgets what she was told, and the caregiver never finds out.
Then there are the medically complex patients who receive zero care coordination and whose families have vast paperwork burdens. Medicaid spenddown, I'm looking at you.
The family is in charge of care coordination. Before starting Primary Record, I tried to start a nurse-led care coordination company to define a community-based role in healthcare. The purpose I served was mere aggregation and interpretation of the health records of 80+ year olds to families. Families are the most incentivized to coordinate better care for aging adults, and their role is completely downplayed in "patient-centered" care. Family caregivers were inspiring to work alongside. By helping share a more complete record in meaningful ways to community organizations and various points in healthcare, I found a value families were paying $85-$125/hour. Now, I am building tech to scale for more families to coordinate their families care because they will always be the ones most invested in the health and outcomes that matter to them.
Olivia, i think you're exactly right, this can be better done. The different collaborative care models try to get at this, but they fall short too. Value based care is going to run into some issues when we try to figure out who or what was all responsible for a outcomes improvement.