A relationship with the Primary Care Physician that is established when a patient is a resident of a skilled nursing facility should not be allowed to end simply because the care was effective and the patient returned home. The care provider who saw the patient on a regular basis, provided direct face to face care, monitored the patient’s history and progress and coordinated treatments by specialists knows the patient better than anyone. Yet most patients in the United States are discharged and told to follow-up with their personal physician, without regard to the fact that their personal physician is probably the one who was providing care while they were a resident.
TapestryHealth is doing exactly this, but most U.S. based skilled nursing facilities are not. Cost is a core issue. Medicare has recently allowed for a transitional care management program (TCM) that allows the doctor who was caring for a patient while in residence to make a follow-up visit within a week, or two weeks in some cases, after discharge. We applaud that but more is needed. Tapestry will see most patients post-discharge as often as is needed to effect proper care but other care providers cannot unless Medicare expands is reimbursement program for remote medical care. We urge everyone to contact their state and national representatives and urge them to expand Medicare coverage to include remote medical care through telemedicine at the patients’ discretion.