Author Archives: Dianne Savastano

Recommended Reading: Primary Care in U.S. and Other Countries

Here is a fascinating study that compares the United States to 11 other countries regarding factors associated with primary care coordination. Unfortunately, the US had the highest rate of poor primary care coordination. It is no surprise that adults with poor primary care coordination are more likely to be hospitalized and to visit the ER.

Are we too clean for our children’s good? This fun article takes a closer look.

Questions to Ask When Choosing a Long-Term Care Facility

When assisting client families, we are often involved in the decision to move an older loved one into a long-term-care facility. This usually occurs following a significant illness; time in an acute care hospital or short-term rehabilitation environment; time at home with private help or at an assisted living facility; or some combination of the above.

Generally, this occurs over a period of years, during which a situation may stabilize for a while, only to be followed by the next crises. At some point, it becomes clear that a long-term-care facility is the best option.

As the selection process begins, we encourage families to visit many facilities. Families want to feel they have the best care possible in place and that they are spending money wisely. It is important to take into account several key factors, including environment, cost, location and, of course, space availability (waiting list of months – or even years – are not unusual).

The cognitive abilities of your loved one will determine how involved he or she may be in the decision to move and in the choice of a facility. Typically, at the point at which long-term-care facilities are being considered, the loved one is not capable of involvement.

This unfortunate reality places a tremendous amount of responsibility, and possibly burden, on the family member(s) tasked with making the “right” decision in the best interest of the older adult. The amount of support in the family (or lack thereof), can contribute to an already stressful time, particularly if poor communication and family disagreement exists.

Develop a list of criteria

Over the years, we have had many clients move to long-term-care facilities. In general, the professionals who work in them are extremely motivated to provide excellent care. That said, there is a great deal of variation in staffing levels, physical environment, and the overall “culture of excellence” that may or may not exist.

In coaching families through the available options, therefore, we encourage them to develop a list of criteria for evaluating potential facilities. Here, for example, are a series of questions that speak directly to the question of, “How do you get to know our loved one?”

  • How do you, as a team in this facility, come to know our loved one?
  • Do you have a formal process by which you learn about a new resident’s history, their family, what they did for a living, what was important to them, what their interests were and what they are now, what their capabilities are now?
  • What is that process and how do we participate in it?
  • Who participates in the process? I am interested in the aides who provide most of the direct patient care, the activities director who plans activities, the nurses and nurse managers who oversee the care being delivered, and the administrators who support all of you.
  • How does the information you gather make its way into the care plan so that all staff who interact with our loved one know this information?
  • How do we participate in the development of that care plan?
  • How do we provide feedback and tweak that care plan as our loved one’s status and capabilities change?
  • Can we meet frequently (at least weekly) during the early transition, and then develop a regular meeting schedule with longer intervals in-between going forward?
  • Who is the best person to share immediate feedback with?
  • What are your recommendations for what we can do during the transition to assist you with getting to know our loved one?

The way in which these and other questions are answered will help family members gain great insight into the care that will be delivered. Ultimately, this may help one facility stand out above the others.


Once family members have made the decision to move a loved one to long-term-care and have helped that individual adjust to their new home, they generally breathe a sigh of relief and can again take on the role of being the husband, wife, daughter, son, granddaughter, or grandson of their loved one.

Their responsibilities do not go away, of course (next month, we’ll address the role of the family once the transition has occurred). Still, if all goes well, it gets easier as these responsibilities are shared with a professional staff.

After all, it takes a wide village to deliver the care that is often necessary as our loved ones age. The key is that we continue to learn from each other.

A Moving Letter

In preparation for an upcoming family meeting at a long-term-care facility at which her father resides, a client wrote a letter and shared it with us in advance of the meeting.

I must say, I was quite moved by her words, as it struck me that this daughter was desperate for her dad to be known as the man he had been his entire life – a dignified man who should be treated with the utmost respect. She was also struggling to hold the facility at which her father lived accountable for the care they promised to deliver.

Click here to read the letter in its entirety.

New Models of Healthcare and How They Affect You

Everyday, we hear about significant changes that may be coming to the Affordable Care Act (ACA). There’s a ferocious debate going on over what should be done. Unfortunately, and as far as I’m concerned, far too much of the discussion focuses on insurance access rather than on how we reduce overall cost.

Healthcare is a $3.4 trillion system, one-third of which (according to many researchers) may be wasteful, not adding value and even causing harm. To me, that’s where the greatest opportunity for improvement lies.

Administrative Barriers

As consumers, a complaint for many of us as we access care is that administrative barriers get in our way. Often, systems are set up to meet the needs of the provider, not the patient. Ironically, I hear the same complaints from primary care physicians themselves, one of whom described the system she works in as, “an environment where I lose a piece of my soul every day.”

In practice, the long-term relationship that must be cultivated and nurtured for a physician to influence a patient to make the changes necessary to impact his/her health, is one that is impossible to foster in today’s transactional-based environment. Instead it requires a culture of “relationship building.”

Fortunately, many physicians are taking it on themselves to move in this direction. A recent Wall Street Journal article titled, With Direct Primary Care, It’s Just Doctor and Patient, describes how some physicians are attempting to do things differently, not only with care delivery but with alternative payment models.

Direct Primary Care Model

Direct Primary Care is one in which a direct relationship exists between the physician and the patient. It bypasses insurance by charging the patient a monthly membership fee. This fee covers things like office visits and some basic laboratory tests and ranges in price from $25 to $85 per month.

A Direct Primary Care arrangement with a practice does not eliminate the need for insurance to cover more costly items, such as diagnostic testing, outpatient procedures and hospitalization. But it may be attractive to people who find themselves in low premium, high deductible health insurance plans in which they must pay the first $5,000 – $10,000 of health care costs before the plan kicks in.

Some of these practices are small and independent and appeal to individual patients, while others are multi-state networks that work with large employers, insurers or unions offering unlimited primary care as part of an employee benefit package. Still others are focused on the Medicare Advantage Plan market and/or insurance for those using Medicaid products.

A major advantage of the Direct Primary Care approaches is that the culture of the practice is different – it is less focused on individual transactions (for which a provider will be paid) and more on what it takes for that provider to influence a patient to make the necessary changes in lifestyle to achieve good health and/or manage chronic disease. Overall, the atmosphere is “relationship based” – more compassionate and less hurried.

These models are often team-based and involve multiple means of communication beyond the in-person visit. Technology is leveraged so that email, texting, video conferencing and group visits are all incorporated into a patient’s experience, thus ensuring that the most appropriate professional, trained at the most appropriate level, is interacting with patients as needed. These teams are led by physicians, and also include nurses, social workers, physical therapists, health coaches, exercise trainers, etc.

Overall, Direct Primary Care practices are considerably less hierarchical than traditional environments. Here, all opinions about healthcare management – including those of the patient – are valued and incorporated into a plan of care.

The success of these practices has been demonstrated in improved patient satisfaction, physician satisfaction, medical outcomes and, lastly, decreased overall cost. And yes, in case you are wondering, I am a fan!

Concierge Practices

While Direct Primary Care Practices often attract lower socioeconomic populations, concierge practices tend to attract more affluent folks (monthly fees range between $100.00 and $250.00).

In concierge practices, physicians limit their patient case load from the usual number of 2,500 – 3,000 patients down to less than 1,000. They also offer visits that are 60-90 minutes long rather than the more typical 20-minute encounter with a traditional practice.

As with Direct Primary Care, participation in these concierge practices also does not eliminate the need for insurance for costlier items, such as hospitalization, etc. However, the fee may include additional services such as the development of a personalized wellness plan and some advanced testing.

Personally, and based on the experience of some of my clients, I’m not sure the higher fees of concierge practices are justified.

What really matters in choosing a practice

We have clients who participate in all manner of practices, including the ones described above, Patient Centered Medical Homes and, of course, more typical primary care practices. Overall, it’s not the structure that determines whether or not patients have a satisfying experience. Rather, it comes down to the following three factors:

  • Ease of access. Every healthcare consumer wants the ability to interact with his/her physician and/or an appropriate healthcare professional when needed. At one time, this was the major advantage of concierge practices. Today, however, and again thanks in no small part to available technology, I’m happy to say that it doesn’t require an additional monthly fee for this to be achieved. The culture and commitment of a given practice in making this a reality is what matters.
  • Coordination of Care. With older adults in particular, coordination of care becomes much more important. One of my patients, an elderly gentleman who at the time was paying nearly $25,000 a year for a concierge practice, needed this as he approached the end of his life. At this point, his physician was totally uninvolved in his care. Instead, and as a result of frequent hospitalizations and the need to transition to a long-term care facility, what his family needed most was assistance with coordination of care across a number of dimensions.
  • Relationship. This may be the most important factor of all. At the heart of things, what we all want is a positive and collaborative relationship with someone we trust, whether that’s our primary care physician, a specialist, or any other healthcare professional with whom we come in contact. And while that should certainty be the foundation for a profession focused on healing people, our current volume-based transactional system often undermines the process.


Alternative delivery models emerge because of multiple factors, including frustrated patients and physicians, as well as (more recently) a desire to provide quality care more efficiently and at less cost. I fully support the innovation that is going on today and applaud those who know things need to change and who are willing to stand up and take action.

And remember, whether you participate in one of these newer models or not, focusing on your relationship with your physician will always hold the key to success.