5 factors to positively propel care transitions


A consistent point of agreement in the ongoing quest to advance the U.S. healthcare system is that vast improvements can be made in the handling of care transitions. Undoubtedly, technology and organizational changes will be brought to bear, but the specifics remain a work in progress.

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"It's going to take a thousand points of light, not just one big thing, to improve costs," said Robert Connely, senior vice president of Medicity, a company that works with hospitals, health systems and physician practices and communities on health information exchange (HIE) solutions. "What we know to be true is that people – in that moment of hospital discharge or transfer – aren't in the best frame of mind or reference for education on what their post-op instructions are," he said. As a result, he said, there's a 20 percent readmission rate to hospitals within 30 days. "That's a huge impact to the cost of the system."

Connely shared 5 areas that can help propel care transitions toward better quality and patient satisfaction en route to reduced cost.

1. Use of HIE technology

The healthcare community has the ability to change how constituents exchange information. This is where HIE comes into play. From hospitals to primary care providers, from patients and the caregivers themselves, HIE infrastructures collect information and deliver it from one point to another allowing for greater communication and collaboration.

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2. Use of EHRs to "predict the future"

"Sure, EHRs are focused on the clinical [lab tests] and financial [deductibles] side of things, but they also provide event-driven data such as referral information and scheduling," Connelly said. "Knowing what needs to happen next is just as important as knowing what happened last."

3. Patient engagement

Patients' inability to manage their own care is one of the biggest drivers for poor care transitions, so education is needed – and not just education of patients. "We need to target [caregivers] to see how we can better advise families during this transition so they can stay ahead of their loved one's health as opposed to dealing with the ramifications of falling behind."

4. Follow-up/human interaction

"The single most documented improvement in transition of care is when nurses follow up with a patient within seven days [of hospital discharge]," Connelly said. Human intercession drives the greatest benefit. Notifying patients of things they should be paying attention to, while advising/ consulting/ reminding them to take their medications on time and clean wounds has an enormous impact.

5. "Playbook" execution

By applying computing intelligence, organizations are looking at best practices from across the world to find the most effective treatments for their patients. "What they need to do [is] similar to use of a playbook in sports," Connelly said. Once an effective treatment is found, a documented action plan needs to be created for the care team, the patient and the patient's caregivers so the patient can recover as quickly as possible.
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