Hospitals, Patient Engagement

Care transitions: Past, present and future of care coordination?

We still have a ways to go if we want to truly improve patient care and outcomes.

“Welcome to the party,” I thought to myself as I walked the floor at HIMSS last month, “it’s about time.” This year, during the nation’s largest healthcare management conference, the term “care transitions” was on everyone’s lips.

Care transitions are the foundation for successful care coordination and a key to the industry’s successful advancement. Unlike some HIMSS buzz words, “care transitions” are here to stay.

The Necessity for Care Transitions

The healthcare industry has made significant strides with the adoption of EHRs, but we still have a ways to go if we want to truly improve patient care and outcomes.

After witnessing first-hand a family member’s hospitalization and the time that was spent on the transition of care, it was apparent that there is a disconnect between hospitals and post-acute facilities. The hospital where my family member was admitted relied on paper, phone and fax to send information to the rehab facility, despite the rehab facility’s use of a care transition solution to electronically manage many of its hospital referrals.

While the case managers played phone tag and waited for the information they needed to relay over fax, my family member stayed in the hospital and we sat in limbo, uncertain where he would end up.

Close the Gaps in Communication

All said and done, my family member’s discharge was delayed about 24-hours, but this brought into the spotlight a much larger issue – that a significant amount of work is still needed to improve the healthcare communication process.

Even though the hospital and rehab facility are part of the same healthcare system, they still rely on a manual process to discharge patients. The root of my frustration was that the hospital’s process not only impacted my family member’s experience, but also added unnecessary stress.

Care Transitions: Central to the Healthcare Evolution

The conversations at HIMSS made it clear that care transitions are finally starting to get the attention they have long deserved. However, based on this personal experience there is a clear need for us to move beyond discussion and towards taking firm action to improve care transitions. Addressing care transitions today will only make healthcare provider organizations stronger as the industry continues to evolve.

Successful Implementation

Some questions for hospitals to consider when making the move towards implementing care transition technology:

1. Begin with the end (user) in mind

  • Who will actually be responsible for collecting and exchanging information across the care continuum?
  • What workflows will make their job easier?
  • How will they be held accountable?

2. How can this improve the workflow of the end user?

  • Will the technology add unnecessary work to providers of care?
  • Will it reduce administrative tasks?
  • Will it standardize workflows and eliminate process variability?
  • Will the technology give providers more time with the patient?

3. Existing and/or future EHR investments

  • Can you build tools/applications on top of your existing IT infrastructure that enhance your EHR?
  • Does the solution interoperate with other EHRs?
  • How long will it take to implement the technology?
  • How long will it take for the technology to have a positive impact on patient care and/or ROI?
  • Can you build the technology in parallel with major capital investments?

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