Question: My mother and father have been married for 63 years, and each is 86. While both see a number of physicians and take a number of prescriptions, we have been fortunate that they have been able to live at home.
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Mom was diagnosed with dementia two years ago and was getting along pretty well until she fell and hit her head two months ago. She was first admitted to the hospital and, within several days, she had become dehydrated and her dementia was much worse. She would not eat, could not walk, did not know anyone, and a feeding tube was inserted.

She was finally discharged to a nursing facility for rehabilitation where she continued losing weight and was severely confused. Our father and family members have taken turns being with her in this most stressful ordeal. When she continued not to respond in the nursing home, we finally learned that 1) the physician who was handling her care in the hospital had stopped all of the medications that her doctors had been prescribing for her and had substituted others, and 2) the same thing happened at the nursing home, where we were limited to the nursing home physician who had only the hospital information.

We immediately called all of her physicians. They, in turn, got in touch with the nursing home physician who had even prescribed medication for a condition she did not have. Once we were able to get her back on the medications that had been working for her, she began gaining weight, started walking, her confusion subsided, the feeding tube has been removed, and she will be going home in the next week.

I am writing you because I believe that, based on what happened with my family, the lack of communication between physicians inside and outside the hospital/nursing home is disruptive to more families than just ours – and dangerous, too. Maybe this will help someone else.

Answer: Based on other reader e-mails and our conversations with several physicians, we agree that there is a lack of continuity of care for seniors with multiple medical problems who are hospitalized for acute problems (like your mother’s head injury) that are overseen by one physician and then, when sent for rehabilitation, are overseen by another doctor.

In addition to a break in regular appointments and contact with regular physicians and staff by your mother, there seems to be a lack of coordination and contact between institutional medical providers and those outside the facility, even though a continuum of care is necessary for quality of care, as you and your family have learned.

In the “old days” when the family doctor handled everything, this was less of a problem, if one at all; however, in today’s world where we deal with a number of specialized medical service providers in various settings, continuity of care may well be lost.

While we understand that maintaining care continuity for a senior who has both acute and chronic medical problems may be difficult, as you point out, lack of it probably caused your mother to be in the hospital and nursing home for longer periods of time, thus increasing the cost.
Patients with complex medical needs and medications suffer when there are breaches in contact when they are admitted to the hospital (and sometimes even during shift changes at a hospital) and then sent to another facility for rehabilitation.

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.