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.