Successful Transitions of Care Require a Focus on IT

Reimbursement models in healthcare increasingly have shifted to reward quality of care over patient volume, placing a greater emphasis on collaboration among organizations before, during and after a hospital visit.

Transition management among hospitals, rehabilitation facilities, primary care offices and other entities profoundly impacts both a patient’s recovery and an institution’s success as a result of that shift.

Technology must be at the foundation of such teamwork. For some organizations, it already is. At St. Luke’s Cornwall Hospital in Newburgh, N.Y., mobile devices help the hospital provide more robust care for some of its most vulnerable patients: its cardiac population.

Technology in Action

In 2014, St. Luke’s Cornwall began a partnership with a local health insurance company in which the insurer pays for electrocardiogram devices that attach to a patient’s smartphone. The hospital distributes the tools to affiliated practices, and doctors at those practices then provide individual devices to patients and train them on use.

The tool allows a patient to take heart rhythm readings remotely and instantly email the results to the doctor. The doctor then can take immediate action to ensure the patient receives timely and appropriate care.

The technology has contributed to reduced readmissions at St. Luke’s Cornwall, and its use, in conjunction with a follow-up program for cardiac patients, contributed to a 17 percent reduction in readmissions by August 2015.

Seniors represent another population poised to benefit from the use of technology in care transitions. About 2.6 million seniors are readmitted to the hospital within 30 days at a cost of $26 billion each year, according to the Centers for Medicare & Medicaid Services. The Center for Technology and Aging believes that technology can assist in improving that landscape, in part by enhancing medication adherence; however, it warns that not all patients or caregivers are on equal footing when it comes to IT use.

The center emphasizes that some individuals adopt technology more slowly than others, or may be unwilling to do so when costs outweigh the potential benefits of utilization.

To that end, it suggests working to determine how the needs of patients correspond with prospective tools before jumping to any conclusions. That means working with technology vendors to develop both a situational assessment and a meaningful deployment strategy.

The Joint Commission, which calls medication management one of seven foundations to support safe transitions of care between settings, says that a lack of effective communication is a significant contributor to medication safety errors following a patient’s discharge from the hospital.

Community projects funded by the Office of the National Coordinator for Health IT (ONC) focused a significant amount of attention on improving communication between hospitals and primary care providers or centralized care managers via the use of automated admission, discharge and transfer (ADT) alerts.

IT Takes a Community

The ADT alerts are built into a hospital’s information system and sent, automatically, to a health information exchange system to ensure proper actions are taken by relevant providers during a patient’s care journey.

ONC notes, in particular, that ADT can assist community partners, such as skilled nursing facilities, with managing transitions for elderly, frail patients to and from hospital settings. Ensuring the connectivity and integrity of those systems is paramount to success, the agency says. Establishing trusted relationships with infrastructure and cybersecurity professionals, therefore, must be a top priority for provider organizations.

Value-based care keeps the healthcare industry on a path where care providers must continue to push for sustained patient health. That means an emphasis on care transitions. Such results, however, cannot be achieved alone. Hospitals, physician practices and other organizations must think proactively, and in tandem with technology partners, for success to become a reality.