The older population—persons 65 years or older—numbered 46.2 million in 2014 (the latest year for which data is available). They represented 14.5% of the U.S. population, or about one in every seven Americans. This number is expected to grow to 21.7% by 2020 and total almost 98 million (double the total in 2014) by 2060.  This population faces unique healthcare challenges, including lack of responsiveness by providers, transportation issues, and an increased complexity of healthcare issues.  These issues expose the need for greater continuity of care for this population. Continuity of care is the process by which the patients and their provider-led care team are cooperatively involved in ongoing healthcare management towards the shared goal of high-quality, cost-effective medical care.

With 85% of this population having one chronic condition and 50% of them having multiple chronic conditions, there is a critical need for long term care plan coordination that involves the patient, their families, care providers, physicians, and other social workers.  Unfortunately, the services being provided to these patients are lagging and fragmented by:

– Patient facilities that are under-staffed with high turnover rates
– Providers who are frequently stretched beyond their capacity
– Services that are provided through silos
– Vertical networks that focus on profit over the overall care for the patients
– Incentives that allow patients to be placed in facilities that aren’t matched to their needs
– Patients and their families who aren’t aware of the care options and choices they have

Transportation is a basic but necessary step for ongoing health care and medication access, particularly for those with chronic diseases. Chronic disease care requires a more comprehensive care coordination that includes clinician visits, medication access, and changes to treatment plans in order to provide evidence-based care. However, without transportation, these patients experience delays in services that lead to a lack of appropriate medical treatment, chronic disease exacerbation and/or unmet health care needs – all of which can accumulate and worsen health outcomes.  Studies have found transportation barriers impacting health care access in as little as 3% or as much as 67% of the population.  While the statistical impacts are variable, there is no doubt that improving access to healthcare for the elderly population is a requirement to decrease overall healthcare costs and to improve the quality of care and quality of life for these patients.

Addressing the lack of responsiveness, transportation, and complexity of care while providing cost-effective, high quality care for the elderly home-bound population is precisely what The Lady with the Lamp addresses.  It is our responsibility to understand the care plan at a macro level and manage its coordination across each of its parts.  We essentially become the care coordinator and advocate for our patients, and this means we’re involved with our patients and their lives beyond just patient visits.  Our business model is designed specifically to allow NPs to spend the time required to coordinate care and meet patient needs rather than focusing solely on the transactional volume of visits. This begins the first moment we travel to see our patients by understanding their current mental and physical state, medical condition, environment, support structure, mobility, medical history, family dynamic, obstacles, and the short and long terms goals of everyone involved.  It includes objectively educating and preparing our patients and families on their options and decisions they will need to make as they move through their journey.  It requires someone to take a macro-level approach to their patient’s care who can assemble information from various sources and provide a continuity of care that keeps them in their homes and out of the hospital.  It requires that we bring our services to our patients, are invested into their care and quality of life, guide our decisions by what is always best for the patient, and respond to their needs throughout our time as their provider.  It is a big responsibility, but by being responsive, improving access to healthcare, and managing the complex nature of our patient’s care comprehensively, our patients will receive the cost-effective, high-quality care they deserve that keeps them in their homes and out of the hospital…just as if they were a part of our own family.