To our readers: Last week, we wrote about the lack of continuity of care for seniors with multiple medical problems who are followed by one set of physicians in the community; by another set when hospitalized for acute problems; and, when sent for rehabilitation to nursing homes or other facilities, by still other physicians.

This column hit a nerve with our readers and spawned significant reader feedback.

If you recall, we wrote about an 86-year-old woman who had been diagnosed with dementia, fell and hit her head at home, and was admitted to a hospital. Within days, her family reported, “she would not eat, could not walk, did not know anyone and a feeding tube was inserted.”

After a hospital stay, she was finally admitted to a nursing home for rehabilitation, where things continued to worsen. Finally, her family learned that (1) the doctors who handled her care in the hospital had stopped all medications that her primary care physicians had been prescribing for her, and had substituted other medications, and (2) that the same thing happened at the nursing home which had access only to the hospital information.

Once the family discovered what had happened, they contacted all of the woman’s physicians, who, in turn, got in touch with the nursing home doctor. Once the medications that had been working for her were restored, she improved dramatically and was able to go home.

We said that according to a deluge of recent e-mails from readers, this lack of continuity of care for seniors is an increasing problem, and that, “while there may be no standardized answer to the problem, family intervention as early as possible appears to be essential to assure contact with, and coordination between, treating physicians outside the facility and those who oversee the patient inside.”

Here is one of the many reader responses to this column:

“Dear Jan and Jan: I felt compelled to respond to your column in our newspaper titled ‘Mom Suffers When Doctors Don’t Share Data.’ As a home-care R.N., I see mostly seniors post-hospitalization or post-rehab. It appears that the first thing the hospitalists [physicians who work at hospitals only, and don’t have their own private practice] do on admission is change every drug the patient has been taking (no matter how long the drugs had been taken or how well they had worked) to the hospitalist’s own regime or to drugs provided by the hospital’s or the rehabilitation facility’s contracted drug provider.

“I routinely see well-controlled diabetics who managed their disease with diet and oral medications for many years who come home from the hospital with their blood sugars off the charts and on several different kinds of insulin. These folks are overwhelmed and terrified of this change. Through conversation I learn that these patients were given a regular diet while hospitalized – no more of the ‘diabetic meals’ that I remember learning in nursing school. Some have even said, ‘The nurse says it’s just easier to give everyone the same food and “cover” them with insulin! How bizarre is that?

“These folks are discharged with a handful of prescriptions and an order to ‘resume prior medications.’ So they fill the new prescriptions AND take the old ones (which have different names, of course). I frequently see people taking duplicate, even triplicate, of the same medications. No wonder they wind up back in the hospital.

“Kudos to the family who advocated for the Mom with dementia. Families/friends need to intervene and insist on coordination between our doctors. Patients are not fragmented, and their care shouldn’t be, either.
“Please continue your column. Our seniors need your voice.”

Taking the NextStep: Thank you for your valuable insights, and thanks for writing. For more information provided by another reader, go to www.nextsteps.net and click on “Continuing Care Among Differing Doctors-Reader Responses". Online readers simply click the related articles link below.