Doctors look to better coordinate care

Taking care of yourself physically, mentally and socially as you age can sometimes seem like a full-time job.

Depending upon your personal circumstances, you need to see a variety of specialists — possibly the ophthalmologist, the cardiologist, the dermatologist or others. And keeping all of their diagnoses, directions and prescriptions straight can be a hassle.

That is why an increasing number of medical practices in the Chicago area and around the country, including the Alexian Brothers Medical Group, are adopting a new model of health care called the Patient-Centered Medical Home approach, said Dr. John Wilkerson, a family practice physician with 26 years of experience who now specializes in the care of senior citizens. He is affiliated with both Alexian Brothers Medical Center in Elk Grove Village and St. Alexius Medical Center in Hoffman Estates, but his practice is based in Elgin.

“Under this model, the family physician acts as the team leader — or quarterback — to coordinate a patient’s care across the health system, including care by specialists, hospitals, home care and community services. He or she helps the patient successfully navigate the health care system,” he said.

“We are trying to make our office the patients’ medical ‘home.’ Our physician assistants, nursing-care managers and medical assistants all work alongside the doctors to make sure our patients receive care in the right place, at the right time and in the way that best suits their individual needs. Since seniors often have multiple problems, there is a great need for coordination of care,” Wilkerson said.

Alexian medical group practices also have dietitians available for diabetic and nutrition counseling; psychologists on staff for the treatment of depression, anxiety and mental health issues; and social workers on hand to arrange home care and coordinate community services.

“We hope that this team approach, led by the patient’s personal physician, will give the best possible results,” he said. “Since our focus is on maintaining wellness and preventing illness, our goal is to concentrate on doing the things that will have the most impact on promoting health — routine screenings for cancer like mammograms and colonoscopies, screening for osteoporosis, immunizations for pneumonia and the flu and lifestyle changes like weight control, smoking cessation and increased exercise.

“We want our patients to develop a strong relationship with their personal physician because we believe this can keep an elderly patient on track,” Wilkerson said. “I’m glad to see this happening. I think that this is what patients want and I also think this is the way doctors want to practice medicine.”

The patient experience is also being enhanced by the fact that Alexian’s practices are offering same-day appointments, Saturday office hours, after-hours care at their immediate care centers, emergency care at their two area hospitals and a new senior emergency department initiative at Alexian Brothers Medical Center. Social workers, psychologists and physical therapists are now available in the emergency room to provide care and support to senior patients and their families before discharge.

The medical group’s practices are also better able to communicate with patients in a timely manner by using a secure web portal where patients may schedule appointments, check lab results and even leave their doctor an email message. This same software is used to communicate between specialties, making patient care more efficient and cost effective.

There is now a recognition process for medical practices to become nationally recognized as medical “homes.” Three of the Alexian group’s offices — Elgin, Barrington and the Older Adult Practice in Elk Grove Village — are in the process of becoming recognized. Once that process is complete, the remaining 11 ABMG offices around the Chicago area will also apply for the recognition, Wilkerson said. The plan is to have all Alexian Brothers group offices recognized as “medical homes” by the end of 2014.

Dr. Wilkerson’s recommendations to his patients:

ŸRegular mammograms and colonoscopies to screen for breast and colon cancer.

ŸAnnual flu shot and regular pneumonia shots.

ŸOne-time shingles shot for those 60 and over. It is not yet covered by Medicare, but Dr. Wilkerson recommends it.

ŸRegular PSA screenings for men over 50 to prevent prostate cancer.

ŸBone density tests once every five years for women over 65.

ŸPeriodic blood chemistry tests to check cholesterol and blood sugar levels, blood proteins, etc.

ŸQuit smoking.

ŸControl your weight and cut back on carbohydrates. An excess of carbohydrates can lead to excess weight gain and diabetes.

ŸEat a balanced diet consisting of fruits, vegetables and meats.

ŸMake sure you get enough vitamin D in your diet. A lack of it can lead to weak bones and osteoporosis.

ŸExercise regularly including resistance training, walking and some light weight training to increase muscle mass. Water exercise is valuable for those with joint problems, in particular.

ŸStay socially engaged by participating in community programs and regularly socializing with friends and family. We all crave a sharing of experiences with other human beings. Isolation can lead to depression.