Clinical communications: The foundation of patient engagement and value-based care

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Value-based care is designed to improve quality outcomes, reduce costs, and provide a holistic view of patient needs. To achieve these outcomes, healthcare organizations must focus on patient engagement, as well as better communication and collaboration among providers and staff throughout the continuum of care.

At Becker's 5th Annual Health IT + Revenue Cycle Conference in Chicago, PerfectServe hosted an executive roundtable to explore patient engagement strategies that support value-based care. Attendees included chief medical officers, directors of health management, and chief information officers. Joe Hickey, PerfectServe's area vice president for the western region, and David Nichols, PerfectServe's product director for patient and family engagement, facilitated a discussion about topics ranging from clinician communications to telemedicine and social determinants of health.

Patient and family communication enhances engagement while reducing the risk of readmission            

Patient and family communication enables health systems to engage patients and provide better care. Appointment reminders, prep instructions, arrival time alerts, and wayfinding support all help patients navigate their care plans more effectively.

Patient and family communication can also lower the risk of hospital readmissions. When patients have an acute care episode, a variety of communications can support their recovery paths. These include ambulatory surgery center post-op calls, inpatient post-discharge communication, and emergency department or urgent care follow-up.

Many healthcare organizations have adopted ongoing outreach as a way to help patients manage their chronic conditions and wellness needs. These programs may offer condition-specific support, health risk assessments, complex care coordination, health coaching, or case management.

Clinical communication and collaboration systems support patient and family communication in several ways, such as:

  • Streamlined care team communications. Nurses and providers can communicate securely. At any moment in time, it is possible to reliably know what provider or care team is directly responsible for a patient.
  • Higher levels of physician engagement. CC&C systems enable physicians to collaborate more efficiently with the care team, while eliminating redundant communications.
  • Enhanced patient safety. Complex organizational structures lead to communication breakdowns between care team members. This can result in delays that jeopardize patient safety. CC&C systems address these issues.

PerfectServe's integrated clinical communications platform serves over 510,000 clinical users and more than 100,000 physicians. The real-time clinical collaboration system connects the entire care team. It provides secure communications and Dynamic Intelligent Routing, so the right information gets to the right person in the right area at the right time.

As Mr. Hickey explained, "PerfectServe synchronizes and brings harmony to the entire care team, including patients, families and providers outside the four walls of the hospital."

Clinician communications — A cornerstone of value-based care

Improving clinician communications is top of mind for many healthcare leaders. Every team member involved with a patient's care must understand what is happening. The CIO for a hospital in the Northwest noted, "In an ACO environment, getting everyone to talk to one another can be a nightmare. Using a clinical communication and collaboration system is a must for keeping costs low and keeping everyone on the same page."

Care team communication is essential for minimizing length of stay and cost per case. Another attendee observed, "We hold 'barriers to discharge' meetings each morning. Coordination can be very fragmented when there are specialties involved. For instance, when physical therapy goes up to the patient room for a discharge evaluation, the patient should actually be there. The CC&C system is the key to addressing issues like these."

Medicare's Promoting Interoperability Program also underscores the need for robust clinician communications. When a patient is admitted to a hospital from the community, a nursing home or another hospital, the admitting hospital is supposed to get a notification through their EHR with the patient's problem list, allergies, medications and summary of care.

One participant whose organization is implementing the Medicare program said, "Communication is a huge storm cloud. Internally, how do we communicate with colleagues inside our facility and between specialties? Communicating with outside physicians is a big black cloud."

Telemedicine — An opportunity to increase post-op quality

Healthcare systems are exploring telemedicine as a way to improve post-operative quality and reduce patient readmission. Organizations are keeping an eye on several key metrics including patient adoption rates of the telehealth portal, patient satisfaction levels, and readmission rates.

The roundtable participants shared best practices for implementing a telemedicine solution. Focusing resources on the initiative is important. One organization found that not having a dedicated team was detrimental. Having the right people at the table who understand the technology is also critical. The senior director of applications at a children's hospital in the Northeast said, "It made such a difference when we identified people who understood the integration points and the third-party video tools."

Social determinants of health provide a more holistic view of patient needs

When healthcare providers gather information about a patient's social determinants of health, it enables care teams to influence the potential outcome for that individual. Without this data, vulnerable patients are discharged back into the community where they may not recover or may be readmitted to the hospital.

One healthcare consulting group based in the Midwest launched a program in partnership with a local university to provide medical and legal advice to patients before they are discharged. The organization's president noted, "The last thing we want is for patients to return to a moldy apartment or to be unable to pay their rent. Our program provides medical and legal resources to advocate for patients."

Leveraging social determinants of health to enhance health outcomes for children is often more challenging than with adults. The senior director of applications at a children's hospital in the Northeast said, "With children the time spectrum is so vast, from the time they are toddlers to adults. It's a struggle to show the value. How do we make investments in things that aren't going to show a return this week, month or year? With children, we are investing for another generation and that's a hard thing for health systems to reconcile."

To gather social determinants of health data, the Midwestern healthcare consulting partner uses assessments when patients are admitted to the hospital or have their first encounter with the emergency department. "We evaluate whether or not they have what they need to be successful when they go back home. That could be diet, food, housing or legal assistance," explained the company's president. Healthy community coaches analyze what is needed to improve public health. Key performance metrics include readmissions rates, as well as ongoing health indicators, and patient participation in follow-up care.


As healthcare providers transition to value-based care, they are realizing that better coordination within their organizations, as well as with other parts of the healthcare ecosystem, is the key to success. This includes communication and coordination with patients and their families. Clinical communications platforms play a central role in keeping all the stakeholders connected.

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