My friend stopped me in the hall the other day. "Does your mom have a healthcare provider yet?" he asked. He knew we were new to the community and that my elderly mother was living with us. "Not yet," I replied. "I just haven't gotten around to it."

He explained what had prompted his question. His 90-year-old father, usually in good health, had recently been hospitalized with atrial fibrillation. His 84-year-old mother, also in fairly good health, had gone to stay with his brother, who lived nearby, while his father was in the hospital. "Bill" had gone to visit them over the holidays and was trying "to help them negotiate the healthcare system."

"What a nightmare," he confided to me. "It doesn't seem like anyone is talking to anyone. Dad went home with a prescription for 5 mg of Coumadin, but he was taking only half a pill-evidently the discharge nurse told him to take half of the pill. Then I took him to the Coumadin Clinic, and the nurse there couldn't find his records, so she 'guessed' (her words) his dosage."

By this time I could tell Bill was getting upset. "It just looked to me like nobody knew what was going on, and to be honest, weren't all that interested."

"Did he have a referral for home care when he was discharged?" I asked (always my first question when friends tell me about their parents who have been hospitalized, and the answer more often than not is "no"). And what I suspected turned out to be true.

"No, there wasn't a referral for home care. I know he needed one, but for some reason, he didn't get it. I should call his physician and get one now," Bill added.

Let me clarify this situation. Bill is an internal medicine physician who refers frequently to home care. His parents live in a large city about 1.5 hours away by plane that had been declared a national disaster area because of a freak winter storm. Many homes, including theirs, had been without electricity for more than a week. Bill's parents live alone and function quite independently, and Bill's brother and family live about 30 minutes away and are available to help.

Nevertheless, it seems that a grave mistake was made by the hospital in not referring Bill's dad for a home care evaluation when he was discharged. The risk factors for rehospitalization and/or emergent care are clearly evident: elderly couple who live alone, new diagnosis (atrial fibrillation), new medication (Coumadin), and weakness, to name only a few.

Bill's parents have many resources. They are well-educated and have financial resources. They have family who are involved and help them frequently. However, Bill's father met criteria for a home health referral through the Medicare home health benefit and should have received an evaluation for home care.

How many people, like Bill's parents, fall through the cracks in the healthcare maze? All too frequently, I hear stories similar to this one from friends and colleagues around the country. With the older adult population burgeoning and healthcare costs skyrocketing, we should be all the more vigilant regarding the home health benefit and our responsibility to make sure those who need it can access it. Billions of dollars are wasted in unnecessary hospitalizations and emergent care visits. How many of these could have been avoided with a more proactive approach to care?

It is time for a change. We may need to start small, but we must demand that our family, friends, and patients receive the home health and hospice benefits to which they are entitled when they qualify and want it. It is the least we can do!!