Rethinking the Approach to Care Transitions

Many people fear being a patient in a hospital. In reality, what happens when the patient leaves is often more confusing, disjointed, and even dangerous.

Discharge planning and patient transitions are of the more complex and challenging moments in the healthcare system. And, as care migrates from hospitals to other facilities, the need for coordinated transitions is even greater.

Studies show that nearly 20% of Medicare patients discharged from a hospital will be readmitted within 30 days as a result of an adverse event, and one in five Medicare patients will experience an adverse event within three weeks of discharge from a hospital.

While these care transitions can be the cause of negative health outcomes, they are not the responsibility of a single provider or facility. Transitions are a challenge to be tackled by our entire healthcare system. In order to improve transitions and outcomes, and reduce costs, providers can do the following to ensure patient safety and satisfaction:

Educate the Patient

Currently, many patients leave the hospital unsure of the details of their diagnosis, and confused about when and how to take their medications. In some cases, their caretaker is equally unaware. When creating a care plan, providers should involve a patient and their caretakers and explain the approach. Many clinicians use the teach-back method, similar to how restaurant waiters repeat orders back to the customer to ensure accuracy. By engaging patients and educating them, patients will be more likely to remember the care plan, trust it, and comply. 

Prioritize Seamless Hand-Offs

The average Medicare patient sees seven providers annually.  Those with chronic or more severe conditions can see up to 25. Rarely do these providers effectively and efficiently communicate with each other. One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between providers. A more robust hand-off communication procedure can facilitate better, clearer, and more effective dialogue among providers, transforming it from a simple “hand-off” of responsibility to a touchpoint along the continuum of care.

Get all Providers on the Same Page

One of the challenges of care coordination and transitions is the simple question of who’s in charge. With the rise of ACOs and clinically integrated networks, patient responsibility is often shared across a team of providers, thus creating an “all-hands-on-deck” approach. These fully integrated care teams have the ability to develop catered interventions, as opposed to piecemealed notes and instructions, to transcend care settings to ensure a safe and successful transition.

Next Steps 

While providers are well positioned to positively influence care coordination and transitions, they also require innovative and practical tools to support their efforts. Real time patient admission and discharge notifications, as well as contextual patient care information, link providers across settings where patients receive care. This allows providers to share and learn about their patients, and keeps others in the loop about patient status.

Rethinking how providers approach the transition process, and incorporating technology into their workflows, is an important first step to ensuring optimal patient outcomes.