Realizing Optimal Outcomes in Care Transitions

Strategies that aim to facilitate communication and reliability

Moving between care settings can be a risky proposition for patients. When transitions are poor, patients may experience delays in treatment, a lapse in care continuity and the omission of vital therapies. Moreover, two-thirds of medical errors occur during care transitions—at admission, transfer or discharge and these breakdowns can have serious ramifications. On one side of the spectrum, a patient could have a slower recovery or a greater chance of acute care readmission; while on the other side, the individual may fail to return to expected functionality, resulting in long-term disability or even death.

Getting a Handle on the Problem

Despite the impact of sub-par care transitions, organizations continue to struggle to effectively move patients from one setting to another. For many, there is a lack of consistent processes, frequent delays and insufficient communication. To improve the efficiency and safety of these critical time periods, organizations should consider the following strategies that aim to facilitate communication and enhance overall reliability.

Initiate discharge early. Although there are exceptions, acute care providers often have a sense right from the moment a patient enters the hospital whether he or she is going to need post-acute care and what type of care that might be. Organizations should capitalize on this knowledge and start the discharge process early, setting expectations with the patient and family and beginning the search for an appropriate facility. This will become even more important given CMS’ proposal to revise discharge planning requirements, making it necessary that hospitals have a plan in place within 24 hours of admission or registration. By launching the process sooner rather than later, an organization can be more careful and intentional with placement and avoid hurried, last-minute transitions. Not only does this ensure better patient outcomes, it also boosts patient and family satisfaction.

Take an interdisciplinary approach. Most patients see a variety of healthcare providers while they are in the hospital including nurses, physicians, nutritionists and physical therapists. Just as this group collaborates to provide comprehensive care while the patient is onsite, they should also be involved in discharge planning. This will help smooth information sharing during the transition and ensure the necessary therapies are in place when the patient leaves the acute setting.

Match the patient’s clinical and psycho-social needs with the receiving facility. Different patients have different needs, and it is critical the receiving organization be able to meet those needs as much as possible. For example, does the patient require physical and occupational therapy? Does he or she need a special type of treatment, such as dialysis? Would he or she fare better if the organization specialized in treating a certain type of condition, such as congestive heart failure? While these factors are important, organizations should also consider psycho-social and clinical factors. For instance, does a patient want her spouse to stay with her overnight? Does she want her pet to accompany her? Is she interested in an organization that is set amidst nature or within a bustling city? Pinpointing the right facility can be challenging, however technology can streamline the process.

By leveraging discharge software that generates a comprehensive and targeted list of facilities that strongly match the patient’s needs, an organization can provide the patient and family with the best options to review. Without such a list, the hospital sets the patient and family up for a difficult and overwhelming process as they attempt to choose a facility without knowing upfront if it will meet their requirements, both clinical and social.

Identify if a patient is high-risk for returning to the hospital. Currently, the discharge process in many hospitals is the same for patients who are at high risk for readmission and those who are not. A high-risk patient may be slow to return to wellness or not respond well to treatment. He or she may have a lack of family support or a history of non-compliance with treatment therapies. Organizations should work to recognize these individuals before discharge and implement intervention protocols to prevent a return visit to the hospital. There are risk stratification and care path tracking tools that can help with this effort, allowing a facility to tailor its discharge processes accordingly.

Pass applicable clinical information to the receiving facility. A key to supporting care continuity is to make sure there is open and effective information exchange between the acute and post-acute organization. This communication should occur before the patient enters the post-acute facility, so it can fill any medication or therapy orders by the time the patient arrives onsite, preventing care lapses. When choosing what information to share, organizations should avoid sending the complete medical record as this can be unwieldy to navigate. A brief description of the pertinent information will be more useful. Technology can support prompt and appropriate information exchange by facilitating communication of concise and relevant data.

A Better Process Yields Better Outcomes

The goal of any care transition improvement effort should be to drive outcomes, with the ultimate objective to create a reliable process that enables seamless care continuity and cultivates patient satisfaction. By taking a targeted, technology-driven approach, organizations can foster robust communication and reduce the likelihood of error, ensuring patients are ready to safely move to the next stage of care.

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