Up to one-half of readmissions from post-acute facilities back to hospitals are avoidable, according to B.J. Boyle, vice president and general manager of post-acute insights at PointClickCare.
"We live in a siloed system, where communication among hospitals and their skilled nursing partners is neither standardized nor coordinated," Mr. Boyle said. "It's common for patients to be transferred from one setting without the necessary infrastructure in place to ensure these transitions will result in positive outcomes for patients."
One strategy for reducing rehospitalizations is to improve data-sharing between acute and post-acute facilities during transitions of care. Many facilities still pass patient documentation to one another via fax or physical packets, resulting in potentially disastrous gaps in continuity of care.
Becker's Hospital Review recently spoke with Mr. Boyle and Sean Vandeweerd, a senior product manager in care coordination and insights at PointClickCare. Here, they discuss the factors that drive avoidable readmissions and what hospitals and post-acute care facilities can do to reduce them.
Editor's note: Responses have been lightly edited for length and clarity.
Question: What does the ideal transition of care process from a hospital to a skilled nursing facility look like?
B.J. Boyle: When you are sitting with a family member or a loved one and you're told they have to move into a post-acute care setting, you want the transition to be as seamless as possible. For that to happen, you need systems that are connected, so when you decide on a post-acute facility, that information will immediately be in the provider's system of record. This enables less time to be spent on the actual transition process and more time to make sure that the care experience is the best it can possibly be.
Sean Vandeweerd: One of the key parts of that is "seamless." It's not uncommon for patients to receive physical copies of their medical information and have the onus placed on them to provide it to the receiving facility. This is far from an ideal process — not just for the caregiver, but also for the patient who's waiting for care to be provided.
Q: What are the typical drivers of readmission from a skilled nursing facility back to a hospital?
BJB: About one-third of all readmissions happen within the first 72 hours, with the leading cause related to medication problems, such as transcription error. Most of those transitions and that documentation still happens via paper or fax, so nurses have to manually enter medication information from physical documents into their EHR. As a result, the No. 1 cause of readmissions comes from when that information wasn't entered correctly and isn't all present and accounted for, which disrupts continuity of care. Next thing you know, a patient may not receive their medication or receives the wrong type or dosage of medication, causing their condition to worsen and triggering a readmission.
SV: Another leading issue that causes readmissions, especially during those first few hours after a transition when patients are most vulnerable, comes from a lack of advance care planning data. This occurs when clinicians and physicians on either side of the spectrum don't have a clear picture of the patient's health and the challenges they were encountering prior to the transition.
Q: Approximately how many of these rehospitalizations are avoidable?
BJB: As you look at avoidable readmissions, it ends up being one-third to one-half, depending on where you are. Overall, avoidable readmission is an approximately $17 billion opportunity in the market.
To make a meaningful difference and to begin to solve this industry challenge, we have to prioritize connected systems and continuity of care. It's not just about manual intervention; it's about systems designed to make sure the data follows the patient and the patient gets the care they should be getting.
Q: What aspects of the transition of care process most impact rehospitalization?
BJB: For one, most of the transition is still a very manual process: The leading way hospitals are communicating with their post-acute partners is through fax.
The second part has to do with timeliness. The hospital needs to get all the information to the post-acute provider in a timely fashion so that there isn't a lag between the time a patient arrives at a skilled nursing facility and the time the information arrives.
Beyond those critical issues of communication and data exchange, there are some other, more technical aspects that can also disrupt the process. For example, it's important that providers work toward achieving consistency in the language they use so there aren't any gaps in the type of care that's given, the care plan or the pathway between a hospital and a post-acute facility.
Q: Besides readmissions, what are some other obstacles to smooth transitions of care?
SV: A "smooth transition of care" doesn't refer just to the ability to prevent a patient from coming back to the hospital — it's also the patient's experience as they're moving from facility to facility.
The patient's experience within a facility, the simplicity of the transition and the family members' ability to be a part of that process, as well as any other caregivers' ability to focus on care rather than on documentation and document management, are all major factors that are impacted by the amount of paper and the amount of broken processes or broken communication throughout the transition.
Conclusion
PointClickCare recently published the results of its 2019 Patient Transition Study. The study found acute care and long-term post-acute care patient coordination remains a primarily manual process, relying on paper, email and fax. In fact, only 11 percent of acute care providers use an integrated EHR, according to the study. These results highlight the major opportunity providers have to improve the transition of care process by simply leveraging more sophisticated tools.
In the study, conducted in partnership with Definitive Healthcare, C-suite executives from acute and post-acute care facilities provided input on data sharing, concerns about interoperability, and other pressing pain points in care delivery and coordination in a blinded, voice-of-customer quantitative study. This study contains important insights for providers looking to improve care transitions and reduce readmissions.
Learn more here.