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Heightened awareness around patient care transitions was forced by the 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, but that’s not all the measures have brought. Overcoming obstacles to patient handovers — whether from the hospital to community (e.g. home, long-term care facility), between hospital units, or from the emergency department (ED) to the inpatient setting — requires a patient-centered focus and efforts to personalize patient outcomes.
The Joint Commission outlines seven elements that must be in place for a safe transition to occur from one health setting to another:
- leadership support
- multidisciplinary collaboration
- early identification of patients/clients at risk
- transitional planning
- medication management
- patient and family action/engagement
- and the transfer of information.
Here are three key solutions that support those elements and improve the seamlessness of patient care transitions.
1. Complete medical records
Communication is the key element in any successful patient hand-off, starting with active listening that leads to thorough documentation. Strategies for completing the patient care record in full should be developed in discipline-specific and specialty-specific ways, to be certain all essential details are included in the transition hand-off. In all cases, it is especially important to identify patients who present risk factors that increase the chance of readmission:
- diagnoses associated with high readmissions
- the need for numerous medications
- a history of readmissions
- psychosocial and emotional factors, such as issues relating to mental health, interpersonal relationships or family matters
- the lack of a family member, friend or other caregiver who could provide support or assist with care
- older age
- financial distress
- deficient physical living environment.
These factors should all be recorded in the patient record and high-risk patients flagged, to ensure that patients are appropriately identified as high-risk and so that appropriate care transition measures can be enacted by providers between settings. However, up to 50% of physician-patient interactions are missing from electronic health records (EHRs).
Using certified medical scribes relieves doctors of the burdens of EHRs, and ensures the accuracy and completeness of documentation by freeing the physician to get the most out of the patient encounter. While scribes record every aspect of the patient encounter, physicians are free to delve into the patient history and current condition, getting the most out of limited time for interaction. The end result is high-quality documentation that can be relied upon over the course of care.
In addition, scribes can be tasked with collecting specific metrics — either about patients themselves, or about whether key targets were hit by providers (e.g. asking about psycho-social issues). These data-management actions result in the creation of baseline data, which are critical to accurately assessing future process changes and improvements.
2. Communication between providers
All too often, communication between providers does not happen. One solution is to use technology to improve communication about the EHR among physicians, nurses and other healthcare providers that see the patient during the course of care. Researchers at Brigham and Women’s hospital have implemented a web-based tool that scans the EHR for the information that doctors and other health workers need to know most. Then it automatically pulls that information into a separate page that’s been designed to highlight those essential details. Of course, the old garbage-in/garbage-out adage is vital here: The technology only works if you have thorough, complete patient information entered into the EHR in the first place.
Other solutions are more process-driven. For example, one top hospital’s approach to care continuity has included developing the role of the “case manager.” In their scenario, a case manager follows patients during the hospital stay, and throughout their stays at a skilled nursing facility (if required), until their arrival to home. The case manager is the point person for the patient and providers, providing care continuity and collaboration; supporting a seamless process for communication of orders; and ensuring additional services coordination, such as home care or transportation upon discharge. The case manager works not only with the patient, but also the family or guardian, which the Joint Commission has noted is important for preventing unnecessary readmissions.
For lower-risk patients, all that may be needed is a “safe handoff form,” which is completed by nurses, physicians and pharmacists, and included in the transfer packet that accompanies the patient to a different facility or home. Different versions can be customized to communicate important information to providers, or to spell out post-discharge instructions (including when to contact a healthcare provider, and whom) for the patients and their families.
3. Regular, scheduled follow-up
Timely outpatient follow-up is a key strategy to reduce hospital readmissions, though half of patients readmitted within 30 days of hospital discharge do not receive follow-up before the readmission. It’s been found that follow-up resources are best spent on high-risk patient targeting, improved communications (including a greater emphasis on language barriers and cultural differences), and better coordination of care and follow-up for high-risk patients in particular could potentially prevent unnecessary readmissions when transitioning patients from the hospital to the home.
Having time frames for meeting goals (e.g. at two weeks, 90% of patients high-risk receive follow-up calls to ask how they are doing with managing new medications and to answer questions) in place cannot only give providers a roadmap for future care, but also a heads-up that things might not be gong as planned. This gives providers a chance to divert patients to lower-cost, lower-acuity care providers earlier, so that high-risk patients do not present to the ED, potentially resulting in readmission. It’s also important to compile the patient education program and follow-up schedule in writing, to create a clear path for patients and their families.
Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.
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