unique⁢ Characteristics of the‍ patient Population

Medicare patients within accountable‍ Care​ Organizations (ACOs) ‍who reside in long-term care facilities present distinct challenges compared to traditional ACO populations, according ⁤to Tom Kim, MD, Chief Medical Officer at Sound Long-Term Care⁣ Management.

These patients typically have a higher number‍ of chronic diseases and,crucially,those illnesses are often more advanced. Many are ⁢nearing the end of life, necessitating a strong focus on advanced ⁤care planning to align medical⁣ treatment with patient and‍ family wishes.

Increased ⁤Coordination of Care needs

A critically important aspect of ‍caring for this population involves​ a greater reliance on others for decision-making. This demands extensive coordination between ⁢the resident, ⁣their ‌families, and other designated decision-makers.

Patients in ​long-term care facilities are ⁤frequently seen by a diverse care team – facility staff, consultants, and various providers. coordinating this care is complicated by fragmented ‍documentation, with details often recorded in multiple Electronic⁢ Health Records (EHRs). Pulling together a thorough patient picture from these disparate sources ‌presents a considerable hurdle.

Fragmented Medical ⁤Records

The challenge of ‍information sharing stems from the​ use of multiple‌ EHR systems. Facility EHRs and individual provider EHRs frequently ‍enough don’t seamlessly integrate, making it arduous to access and share ‍pertinent patient information efficiently. This fragmentation impacts the ability to deliver truly coordinated and informed care.