5 steps to improve care transitions

Transitions in care can have significant financial impact on healthcare organizations. As technology improves and business paradigms shift, organizations have an opportunity to reduce costs and improve care quality. However, challenges await: it's not easy to make improvements in care transitions.

"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 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." 

[Also: Communication key to improving care transitions]

Connely shared with Healthcare Finance News five steps to improve care transitions for better quality and patient satisfaction en route to reduced cost.

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

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."

[Also: 7 ways to prevent overspending on EHRs]

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 of the patients. "We need to target (the caregivers) to see how we can better advise them 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 the best practices from across the world to fnd the most effective treatments for their patients. "What they need to do (is) similar to that 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.