Most of the nursing home patients I encounter seem to be in limbo. Their family doctors usually stop following them in the ECF, and they are followed from a distance by the doctors at the facility. So, at the time when these patients need more regular monitoring and coordination of care, nobody is really paying attention.

Much of this would change quickly if the government did two things.

First, every ECF should have an NP or PA who sees patients on a regular basis and takes care of the issues that can be handled there. The government should reimburse reasonable charges for this. Smaller ECFs could share staff. These practitioners could head off problems by monitoring conditions such as UTIs,

G-tube issues, medication problems, and bedsores, which often turn into bigger problems when ignored.

Second, the nursing homes need to take some ownership of the problem. The doctor at the ECF should be required to approve and certify every ambulance trip. Pointless trips should be charged back to the ECF. All of a sudden, the ECFs will take a closer look at who needs to come to the ED. The reflex response of “Send him to the ER” will change, and the doctor will ask questions and think of reasonable alternatives before ordering the $200-per-mile horizontal limo ride.

If one ambulance trip per day per nursing home were prevented, it would save more than $5 billion annually. That would move us farther from the point of having to deny care.

And that point is coming.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.