Bridging the Care Transition Gap

Harry Greenspun, M.D.Good patient care requires an enormous amount of information to be conveyed, both within care teams and from setting to setting, Greenspun says. IT collaboration tools can help coordinate teams, make clear where responsibilities lie, and help make sure that things don’t get dropped and are not duplicated, he says.He has observed increasing appreciation among provider organizations that transitions are actually a dangerous time for patients, which is being reflected in the changing nature of discharge summaries. “In the past, discharge summaries were focused on what happened, as opposed to here are the goals, here is what needs to be done and this is what has been done so far, and what information needs to be handed off to make the transition successful,” he says.Greenspun notes that there is no single solution to optimizing care transitions. The ability to pull information together from different sources and make sense of it is important. One problem in the industry has been that there are a lot of technology solutions directed at a narrow piece of the puzzle, but they haven’t been incorporated well into what Greenspun calls the “people-process-technology triad. You can solve one problem” he says, “like a great care coordination application. But if the data isn’t there, or people can’t access it, or it’s not easy for the clinician to use it as part of their daily routine, it’s not a real advance.”Erica Drazen, managing director at the Global Institute for Emerging Healthcare Practices at Falls Church, Va.-based CSC, notes that most provider organizations did not choose care transitions as part of their Stage 1 meaningful use attestation. She says care management transitions will become a front-burner issue with the emergence of accountable care and incentives to reduce readmissions.

Erica DrazenWhere should hospitals initially focus their attention? Drazen says the smart money would focus on diagnoses. “The most costly patients, from a hospital’s perspective, are more likely to need coordinated care, since they tend to go back into the hospital,” she says. Medication lists also rank high: “If you have a medication list, at least you know what a patient’s likely problem looks like,” she says, adding that medication lists are a small, but a key, part of the continuity of care document.A Time for TeamworkPat Rutherford, R.N., vice president of the Institute for Healthcare Improvement, Cambridge, Mass., says there is a new awareness of the importance of care transitions compared to just five years ago, although there is still plenty of work to do in filling the patient engagement gap.She sees a need for better partnerships between IT solution vendors and quality improvement experts, to create system-wide solutions in an infrastructure that is often fragmented. Vendors need to sit down with clinicians who actually use the products, she says.Hospitals are in a position to assess a patient’s comprehensive needs, but handoffs of patient information need to be designed to be useful for the end users, and not necessarily written from the hospital’s perspective, she says. Some of the information that skilled nursing facilities, home healthcare agencies, and primary physician offices maintain may be the same, but other information may be different, she says. “We will get better compliance on what patients need to do to care for themselves if we do a better job of conveying information in a simple, clear way,” she says. She describes the hospital’s role as a “pay it forward” dynamic of providing the information that the next provider of care needs, and what it can do to make that transfer of information successful.For that to happen, each caregiver needs information that is tailored to his or needs to make the best decision, Rutherford says. What’s needed by each caregiver is a one-page summary of information that is relevant to their caregiving role.Rutherford believes that changes taking place under healthcare reform can improve care transitions by providing care that is customized to the patients’ needs and preferences in every site of care, and then build connections to the whole continuum of care. “We need to be more patient-centered, and we need to think about care experiences over time,” she says.