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Better care transitions yield better outcomes

Mary Kay Thalken, RN, MBA, Chief Clinical Officer, Ensocare

Healthcare organizations have long struggled with care transitions, especially when moving complex patients who require multifaceted care from acute settings to a post-acute environment. These transitions are often fraught with communication breakdowns, poor information exchange and slow responses to changing patient conditions. As a result, patients frequently don’t receive the care they need, or that care is delayed, causing them to end up back in the hospital. According to the Centers for Medicare & Medicaid Services (CMS), nearly 20 percent of Medicare patients discharged from a hospital are readmitted within 30 days, at a cost of more than $26 billion every year. Not only do inadequate transitions have ramifications from a cost perspective, they also negatively affect patient satisfaction and the overall patient experience.

Left unchecked, the issue of poor care transitions will continue to decline as the population ages. In fact, it is estimated that by 2030, one in five U.S. residents will be 65 years or older, and since older patients are more apt to visit the hospital and require post-acute care after discharge, it is becoming even more critical for these care transitions to be smooth and seamless.  

Insufficient communication is the main reason why care transitions break down. When organizations do not have processes and systems in place to facilitate consistent information exchange, important data can be lost, increasing the risk for potential issues that could occur. Additionally, it is estimated that 80 percent of serious medical errors are attributable to miscommunication during hand-offs, and these communication deficits often lead to poor, if not detrimental outcomes.

Emerging technology presents an opportunity

With the explosion of diverse healthcare IT solutions in recent years, hospitals have an opportunity to use technology to make a substantial dent in the issue of sub-par care transitions. More specifically, care coordination technology can assist hospitals in boosting the reliability and efficiency of care transitions while mitigating readmission risk and improving a patient’s clinical and psychosocial outcomes. These solutions can have a surprisingly big impact on key metrics such as readmissions – in some cases organizations have seen a 50 percent reduction.

Here are three areas where care coordination technology can make a difference.

Appropriate placement. When patients who require complex care leave the hospital, it is essential they move to a facility that is capable of delivering the care they need in a timely, efficient and dependable manner. Historically, hospitals have relied on word of mouth, geographic proximity and other subjective indicators when recommending the best places for post-acute care. However, with automated care coordination technology, staff can follow a more data-driven approach, inputting a series of patient characteristics – both clinical and psychosocial – into the software and receiving a comprehensive list of post-acute facilities  that best meet the patient’s unique needs. Staff can also review data that show which organizations have the best outcomes for certain types of conditions, such as congestive heart failure or recovery from joint replacement.

Smoother information sharing. One particular pitfall of care transitions involves information exchange. It is not unusual for patients to arrive at a post-acute facility with their medical records literally sitting on their laps. Not only has the receiving organization not seen the record ahead of time, but the document is so unwieldy it is difficult to obtain information quickly, if at all. The organization is unable to adequately prepare for a patient’s visit, which can result in care gaps or omissions. However, by using care coordination technology, hospitals can send a succinct report to the receiving facility ahead of the patient’s arrival, allowing the post-acute provider to prepare medication orders, therapy scripts and treatment plans ahead of time. This electronic document includes the most pertinent information, and it is directly imported into the medical record, so post-acute providers can access crucial data any time they need it.

Faster response to changing conditions. When patients with multiple co-morbidities leave the hospital, their conditions are sometimes precarious. If a patient neglects to take prescribed medication, misses a follow-up appointment, or experiences some change in vital signs, it can quickly lead to rehospitalization. However, research has shown that patients at risk for complex care transitions can be identified using data available at the time of hospital discharge. Care coordination technology can use this data to model whether a patient is at-risk, allowing hospitals to implement proactive interventions that mitigate concerns. Also, communication tools that encourage all members of the care team – hospital case managers, post-acute providers, primary care physicians and the family – to share information can ensure a more rapid response.

The benefits are clear

There are significant advantages to using technology to make care transitions more reliable. For example, software that better matches patients with post-acute providers can reduce length of stay in the hospital because the patient can make faster, more informed decisions, thus, preventing delays. Timely data exchange between organizations can prevent medical errors because the post-acute provider has all the information they need to design and implement the care plan before the patient arrives onsite. Tools that assess risk can help hospitals be more proactive, foster collaboration between settings and limit the chances of readmissions.

As the population ages, the need for well-designed care transitions will increase dramatically. By leveraging care coordination technology, organizations can address this issue, improving outcomes, reducing costs and elevating the patient experience.