People With Serious Illness Need a Continuum of Care

The needs of older adults with serious illness are too often overlooked by the health care system. For many, comprehensive care for serious illness occurs only in the last weeks and months of life as they enter hospice care. Until that point, the frail and elderly tend to stop going to medical offices for care and begin using emergency rooms for ongoing medical treatment, which is both costly and detrimental to the patient. Unlike many other hospice organizations, Gilchrist has redefined end-of-life care to provide services at every stage of serious illness that includes a continuum of care.

Changing the Way We Care for People With Serious Illness

At Gilchrist, we believe it doesn’t make sense to wait until a person has six months left to live to start providing services. Instead, we provide care for a person from the time of their diagnosis throughout the end of life, gradually increasing services as their condition progresses. This continuum of care prevents unnecessary and unwanted hospital visits and allows people to age in place.

Gilchrist’s physicians and nurse practitioners have the expertise to provide specialized care for older adults with chronic conditions. They can oversee and coordinate care for patients who may have multiple conditions. They also manage a patient’s medications, taking into account how multiple medications that may have been prescribed by different specialists interact with each other.

In between home visits, patients have access to Gilchrist’s 24/7 on-call nursing support line to answer questions or provide assistance if a medical crisis arises. A social worker and resource coordinator are also available. When the patient is ready, they can be seamlessly transitioned to hospice.

Gilchrist’s programs include home-based patient-centered Elder Medical Care, Geriatric Consultations, Rehabilitation, Palliative Care, Hospice Care and many other services to meet the needs of older individuals with serious illness.

Why Is a Continuum of Care Important?

Without a continuum of care, many seniors seek care only when a crisis arises. Unfortunately, hospital emergency departments are not ideal providers of ongoing care. They are meant to offer short-term care in the event of an emergency. Hospital doctors see only a snapshot of a person’s condition, unlike a personal physician who knows and understands their medical history.

Furthermore, studies have found that repeated hospitalization may have negative health consequences, such as further decline and fragility and reduced quality of life.  

The need for a comprehensive continuum of care for people with serious illness is great. A recent study published in the American Journal of Accountable Care found that, for people with serious illness:

• Their symptoms are often inadequately addressed. For example, 64% of people with metastatic cancer report high levels of pain, despite being under the active care of an oncology team.
• Communication and shared decision making are insufficient. For example, fewer than 50% of hospitalized patients with a serious illness were ever asked what their personal preferences would be if a critical situation should arise.
• Only 47% of discharged patients report fully understanding their discharge instructions.
• The outsized responsibilities placed on family caregivers are taking an enormous toll. More than 1 in 5 cite adverse impacts on their own health, and formal studies conclude that caregivers face a 63% increased risk of mortality.

Our Commitment to People With Serious Illness

Gilchrist is committed to ensuring that elders who can no longer safely and easily leave their home receive the care and support they need. Seeing people earlier in the course of their illness and offering a continuum of care ensures no person falls through the cracks of the health care system.

To learn more about Elder Medical Care and Gilchrist’s continuum of services, visit gilchristcares.org/elder-medical-care.